Provider Demographics
NPI:1467127522
Name:YACONO, JOHANNA ROSE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:ROSE
Last Name:YACONO
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 1:2059 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6242
Mailing Address - Country:US
Mailing Address - Phone:917-691-2989
Mailing Address - Fax:
Practice Address - Street 1:3104 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4200
Practice Address - Country:US
Practice Address - Phone:718-339-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383164363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics