Healthcare Provider Details

I. General information

NPI: 1205069770
Provider Name (Legal Business Name): SUSANNE P JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST STE 3
MANNING SC
29102-3149
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-8828
  • Fax: 803-435-2239
Mailing address:
  • Phone: 803-435-5270
  • Fax: 803-433-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3937
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: