Healthcare Provider Details

I. General information

NPI: 1427556349
Provider Name (Legal Business Name): CANDACE JOHNSON WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 OLD AIRPORT RD
HATTIESBURG MS
39401-8382
US

IV. Provider business mailing address

252 PENNY LN
BRANDON MS
39042-7558
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-4550
  • Fax: 601-582-3373
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number902209
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: