Healthcare Provider Details

I. General information

NPI: 1659745263
Provider Name (Legal Business Name): HEIDI JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-8630
  • Fax: 603-650-2240
Mailing address:
  • Phone: 207-973-7334
  • Fax: 207-626-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number086110-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP151174
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: