Provider Demographics
NPI:1053175935
Name:JOHNSON, EMILY ANTONIA
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANTONIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06412-1121
Mailing Address - Country:US
Mailing Address - Phone:860-304-7933
Mailing Address - Fax:
Practice Address - Street 1:234A BANK ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8018
Practice Address - Country:US
Practice Address - Phone:860-442-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12866363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily