Healthcare Provider Details

I. General information

NPI: 1629238704
Provider Name (Legal Business Name): LYNNETTE MARIE JOHNSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-5001
US

IV. Provider business mailing address

601 ELMWOOD AVENUE BOX 651
ROCHESTER NY
14642-5001
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-6345
  • Fax:
Mailing address:
  • Phone: 585-275-2972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number311059
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: