=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427056472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA V JOHNSON APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 04/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 TOWER LN STE 104
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-4237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-983-0655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 TRAINOR DR
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-983-0655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 000838
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------