Provider Demographics
NPI:1730186834
Name:JOHNSON, JENNIFER LYNN (CRNA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EAST RIVER DRIVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-0833
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3300
Practice Address - Country:US
Practice Address - Phone:860-545-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014117367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263069OtherTRICARE
AR159253001Medicaid
MO917262909Medicaid
MO917262909Medicaid