Healthcare Provider Details

I. General information

NPI: 1013518794
Provider Name (Legal Business Name): JOHNSON OPPONG PSYCHIATRIC NURSE PR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2020
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453-4303
US

IV. Provider business mailing address

1808 ROUTE 6
CARMEL NY
10512
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-7295
  • Fax: 718-299-6797
Mailing address:
  • Phone: 845-225-2700
  • Fax: 845-225-3207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF4031-75
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: