Healthcare Provider Details

I. General information

NPI: 1811603921
Provider Name (Legal Business Name): MARY ELIZABETH JOHNSON WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STONE CREEK BLVD STE 200
FLOWOOD MS
39232-8210
US

IV. Provider business mailing address

1008 SHILOH RUN DR
CRYSTAL SPRINGS MS
39059-8758
US

V. Phone/Fax

Practice location:
  • Phone: 601-822-2294
  • Fax: 601-793-4273
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number918717
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number906992
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: