Healthcare Provider Details

I. General information

NPI: 1710648050
Provider Name (Legal Business Name): NEKESHA MICOLE JOHNSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2022
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 J K AVENT DRIVE
GRENADA MS
38901
US

IV. Provider business mailing address

1100 COLLEGE ST
COLUMBUS MS
39701-5821
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905012
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: