Provider Demographics
NPI:1073652830
Name:JOHNSTON, EVELYNN (NP)
Entity Type:Individual
Prefix:
First Name:EVELYNN
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1198
Mailing Address - Country:US
Mailing Address - Phone:973-736-2212
Mailing Address - Fax:973-736-2989
Practice Address - Street 1:769 NORTHFIELD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1198
Practice Address - Country:US
Practice Address - Phone:973-736-2212
Practice Address - Fax:973-736-2989
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN08286800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22300Medicare UPIN
NJ081941A4GMedicare ID - Type Unspecified