Provider Demographics
NPI:1275093460
Name:JOHNSON, MABEL YATTA (NP)
Entity Type:Individual
Prefix:MS
First Name:MABEL
Middle Name:YATTA
Last Name:JOHNSON
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 1:24 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-1779
Mailing Address - Country:US
Mailing Address - Phone:978-995-2533
Mailing Address - Fax:888-340-6599
Practice Address - Street 1:81 BRIDGE ST # 215
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1270
Practice Address - Country:US
Practice Address - Phone:978-459-2306
Practice Address - Fax:978-453-9394
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA265003163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent