Healthcare Provider Details

I. General information

NPI: 1265049324
Provider Name (Legal Business Name): JOHANNA CATHERINE MCKENNA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOHANNA CATHERINE LAKE

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 OLD ETNA RD
LEBANON NH
03766-1970
US

IV. Provider business mailing address

2802 URBANA DR
SILVER SPRING MD
20906-5033
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax: 603-640-1228
Mailing address:
  • Phone: 603-630-4454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR220471
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111369-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: