Provider Demographics
NPI:1912716200
Name:JOHNSON, LARA CRISTINA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:CRISTINA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2343 PURCHASE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02746-1555
Mailing Address - Country:US
Mailing Address - Phone:781-436-3352
Mailing Address - Fax:
Practice Address - Street 1:3 SAINTS WAY
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MA
Practice Address - Zip Code:02779-1343
Practice Address - Country:US
Practice Address - Phone:508-292-1791
Practice Address - Fax:469-746-7555
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2279515163W00000X, 363LP0808X
RIAPRN04545363LP0808X
RIRN79950163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse