Healthcare Provider Details

I. General information

NPI: 1326060690
Provider Name (Legal Business Name): MARY JOHNSON A.C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 619-13 ADULT NURSING
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 619-13 ADULT NURSING
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5875
  • Fax: 585-271-7929
Mailing address:
  • Phone: 585-275-5875
  • Fax: 585-271-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number430107
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF4301071
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: