Provider Demographics
NPI:1992940266
Name:D'ADDARIO, JOHANNA LAINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:LAINE
Last Name:D'ADDARIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JOHANNA
Other - Middle Name:LAINE
Other - Last Name:CHELCUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1744
Mailing Address - Country:US
Mailing Address - Phone:212-920-1857
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT2578363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant