Provider Demographics
NPI:1336388032
Name:JOHNSON, DIANA ELLEN (APRN)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:ELLEN
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 1:2 RACHEL LN
Mailing Address - Street 2:
Mailing Address - City:IVORYTON
Mailing Address - State:CT
Mailing Address - Zip Code:06442-1154
Mailing Address - Country:US
Mailing Address - Phone:860-304-0469
Mailing Address - Fax:
Practice Address - Street 1:2 RACHEL LN
Practice Address - Street 2:
Practice Address - City:IVORYTON
Practice Address - State:CT
Practice Address - Zip Code:06442-1154
Practice Address - Country:US
Practice Address - Phone:860-304-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002865364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent