Provider Demographics
NPI:1174004782
Name:JOHNSON, EBONY TASHA (APRN)
Entity Type:Individual
Prefix:MS
First Name:EBONY
Middle Name:TASHA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 FOXON RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-2037
Mailing Address - Country:US
Mailing Address - Phone:203-533-5911
Mailing Address - Fax:475-238-6372
Practice Address - Street 1:444 FOXON RD
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-2037
Practice Address - Country:US
Practice Address - Phone:203-533-5911
Practice Address - Fax:475-238-6372
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008082536Medicaid
CT7774OtherAPRN LICENSE