Healthcare Provider Details

I. General information

NPI: 1255088167
Provider Name (Legal Business Name): DONNA LAUREN JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 FRONT ST
SANDERSVILLE MS
39477
US

IV. Provider business mailing address

688 JOE PERRETT RD
LAUREL MS
39443-0746
US

V. Phone/Fax

Practice location:
  • Phone: 601-490-7190
  • Fax:
Mailing address:
  • Phone: 601-319-1837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number905187
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: