Healthcare Provider Details

I. General information

NPI: 1255999595
Provider Name (Legal Business Name): KIARA D JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2019
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 601-362-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number903298
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: