Provider Demographics
NPI:1629486477
Name:LAM, JOHANNA FORMAN (NP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:FORMAN
Last Name:LAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:FORMAN
Other - Last Name:KAPLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 WASHINGTON ST STE 544
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1624
Mailing Address - Country:US
Mailing Address - Phone:617-910-0368
Mailing Address - Fax:888-806-8144
Practice Address - Street 1:2000 WASHINGTON ST STE 544
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462
Practice Address - Country:US
Practice Address - Phone:617-910-0368
Practice Address - Fax:888-806-8144
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2276817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400174511Medicare PIN