Provider Demographics
NPI:1922194315
Name:JOHNSON, MARY ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:LACROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 OLD CENTER RD N
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03037-1310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 ROUTE 27
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:NH
Practice Address - Zip Code:03077-1220
Practice Address - Country:US
Practice Address - Phone:603-895-3351
Practice Address - Fax:603-895-0773
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH018811-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S83985Medicare UPIN
NP1890Medicare PIN
NH30011691Medicaid