Healthcare Provider Details

I. General information

NPI: 1205922747
Provider Name (Legal Business Name): TAMI BIVINS JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603B HWY 365 BURNSVILLE MEDICAL CLINIC
BURNSVILLE MS
38833
US

IV. Provider business mailing address

2006 NORTH MADISON STREET
CORINTH MS
38834
US

V. Phone/Fax

Practice location:
  • Phone: 662-427-9999
  • Fax: 662-427-9977
Mailing address:
  • Phone: 662-287-6811
  • Fax: 662-427-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR605972
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: