Provider Demographics
NPI:1841424801
Name:JOHNSTON, MARY LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:203-785-4216
Mailing Address - Fax:203-737-6014
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YPB 4TH FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-4191
Practice Address - Fax:203-737-6014
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002311363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003990Medicaid
CT008003990Medicaid