Healthcare Provider Details

I. General information

NPI: 1861303745
Provider Name (Legal Business Name): RELENA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W PEACE ST
CANTON MS
39046-4535
US

IV. Provider business mailing address

115 W PEACE ST
CANTON MS
39046-4535
US

V. Phone/Fax

Practice location:
  • Phone: 414-534-0565
  • Fax:
Mailing address:
  • Phone: 414-534-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number894844
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: