Healthcare Provider Details

I. General information

NPI: 1669975587
Provider Name (Legal Business Name): CAROLYN S JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROLYN S JOHNSON FNP

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 FRENCH RD
INDIANOLA MS
38751-9605
US

IV. Provider business mailing address

1027 FRENCH RD
INDIANOLA MS
38751-9605
US

V. Phone/Fax

Practice location:
  • Phone: 662-466-0330
  • Fax: 662-756-0931
Mailing address:
  • Phone: 662-466-0330
  • Fax: 662-756-0931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License NumberR800714
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: