Healthcare Provider Details

I. General information

NPI: 1669912457
Provider Name (Legal Business Name): LUISA JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LUISA WONDRA APRN

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DOCTORS PARK
CAIRO GA
39828-3072
US

IV. Provider business mailing address

1 DOCTORS PARK
CAIRO GA
39828-3072
US

V. Phone/Fax

Practice location:
  • Phone: 229-378-8110
  • Fax: 229-378-8109
Mailing address:
  • Phone: 229-378-8110
  • Fax: 229-378-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9258834
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9258834
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN328484
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: