Provider Demographics
NPI:1316957285
Name:JOHNSON, DIANE (PMHNP (APRN))
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP (APRN)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 HAWLEY LN FL 3
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1202
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-444-5114
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:NORTHEAST MEDICAL GROUP, INC.
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-444-5114
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2409363LP0808X
CT002409363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316957285Medicaid
RI1316957285Medicaid