Healthcare Provider Details

I. General information

NPI: 1497240378
Provider Name (Legal Business Name): DIANA LYNN JOHNSON CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 VT ROUTE 149
WEST PAWLET VT
05775-9798
US

IV. Provider business mailing address

1608 MILL POND RD
WELLS VT
05774-9911
US

V. Phone/Fax

Practice location:
  • Phone: 802-645-0580
  • Fax:
Mailing address:
  • Phone: 802-645-9521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number0260019756
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: