Healthcare Provider Details

I. General information

NPI: 1396162582
Provider Name (Legal Business Name): LOU JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 11/23/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 MAIN STREET
MONETTA SC
29105
US

IV. Provider business mailing address

P O BOX 92 267 MAIN STREET
MONETTA SC
29105
US

V. Phone/Fax

Practice location:
  • Phone: 803-685-7002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number64015
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: