Provider Demographics
NPI:1285154583
Name:JOHNSON, MINA (PMHNP)
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3701
Mailing Address - Country:US
Mailing Address - Phone:914-401-0008
Mailing Address - Fax:914-401-0009
Practice Address - Street 1:369 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3701
Practice Address - Country:US
Practice Address - Phone:917-539-0810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720423-1163W00000X
NYF402418-1363LP0808X
NYF402418363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse