Healthcare Provider Details

I. General information

NPI: 1205340007
Provider Name (Legal Business Name): MISTY JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MASONIC DR
ALEXANDRIA LA
71301-3841
US

IV. Provider business mailing address

919 HIDDEN RDG
IRVING TX
75038-3813
US

V. Phone/Fax

Practice location:
  • Phone: 318-448-6700
  • Fax:
Mailing address:
  • Phone: 469-282-2713
  • Fax: 469-282-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR133302
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09665
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: