Provider Demographics
NPI:1194590109
Name:JOHNSON, EMILY GRACE (AGNP-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 BAYLIES ST
Mailing Address - Street 2:
Mailing Address - City:NORTH DIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02764-1336
Mailing Address - Country:US
Mailing Address - Phone:774-218-9179
Mailing Address - Fax:
Practice Address - Street 1:266 BAYLIES ST
Practice Address - Street 2:
Practice Address - City:NORTH DIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02764-1336
Practice Address - Country:US
Practice Address - Phone:774-218-9179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309136363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner