MEDICARE: MARY ANNA JOHNSON FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	5011650	NC

General Provider Information

NPI Number	:	1720541220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ANNA JOHNSON FNP-BC

Provider Business Mailing Address
First Line	:	POST OFFICE BOX 968
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466
Country	:	US
Telephone Number	:	910-285-4100
Fax Number	:	910-285-4766

Provider Business Practice Location Address
First Line	:	207 E MURPHY ST
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1946
Country	:	US
Telephone Number	:	910-285-4100
Fax Number	:	910-285-4766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	02/24/2021

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