Healthcare Provider Details

I. General information

NPI: 1114778065
Provider Name (Legal Business Name): CONNOR ELIZABETH JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNOR ELIZABETH FROST

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 MATTHEW DR
WAYNESBORO MS
39367-2565
US

IV. Provider business mailing address

1021 HIGHWAY 17
SILAS AL
36919-5538
US

V. Phone/Fax

Practice location:
  • Phone: 601-735-5151
  • Fax:
Mailing address:
  • Phone: 205-604-8230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906604
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: