Provider Demographics
NPI:1922347335
Name:JOHNSON, MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 QUARRY RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4816
Mailing Address - Country:US
Mailing Address - Phone:203-374-6162
Mailing Address - Fax:203-374-1549
Practice Address - Street 1:112 QUARRY RD
Practice Address - Street 2:SUITE 220
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4816
Practice Address - Country:US
Practice Address - Phone:203-374-6162
Practice Address - Fax:203-374-1549
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5134363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1922347335Medicaid