Provider Demographics
NPI:1366096745
Name:JOHNSON, VINCY MARIA (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:VINCY
Middle Name:MARIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MRS
Other - First Name:VINCY
Other - Middle Name:MARIA
Other - Last Name:KIZHAKKEPARAMBIL JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8458
Mailing Address - Country:US
Mailing Address - Phone:631-968-3000
Mailing Address - Fax:631-968-3813
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8458
Practice Address - Country:US
Practice Address - Phone:631-968-3000
Practice Address - Fax:631-968-3813
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF431550-01363LA2100X, 363L00000X
NJF431550-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care