Provider Demographics
NPI:1831825686
Name:JOHNSON, MARY ELLEN (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:PASSINEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1783 ROUTE 9 STE 102
Practice Address - Street 2:
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-2467
Practice Address - Country:US
Practice Address - Phone:518-383-4198
Practice Address - Fax:518-383-0448
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily