Healthcare Provider Details

I. General information

NPI: 1811127038
Provider Name (Legal Business Name): VIVIAN TINA JOHNSON RN, NPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 RT 25A SUITE 5
ROCKY POINT NY
11778-9089
US

IV. Provider business mailing address

538 ROUTE 25A SUITE 5
ROCKY POINT NY
11778-9089
US

V. Phone/Fax

Practice location:
  • Phone: 631-891-7316
  • Fax: 631-821-3016
Mailing address:
  • Phone: 631-891-7316
  • Fax: 631-821-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF-400187-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberF400187-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: