Healthcare Provider Details

I. General information

NPI: 1144245671
Provider Name (Legal Business Name): PATSY JOHNSON CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

PO BOX 520
ROLLING FORK MS
39159-0520
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-4361
  • Fax: 662-873-2921
Mailing address:
  • Phone: 662-873-4361
  • Fax: 662-873-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR559784
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: