Healthcare Provider Details

I. General information

NPI: 1649108366
Provider Name (Legal Business Name): JHALYSA JOHNSON FPA-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 N GOODMAN ST STE D103
ROCHESTER NY
14607-1173
US

IV. Provider business mailing address

274 N GOODMAN ST STE D103
ROCHESTER NY
14607-1173
US

V. Phone/Fax

Practice location:
  • Phone: 585-514-0653
  • Fax:
Mailing address:
  • Phone: 585-514-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0948
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: