Healthcare Provider Details

I. General information

NPI: 1861629040
Provider Name (Legal Business Name): LISA A JOHNSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-6006
  • Fax:
Mailing address:
  • Phone: 304-647-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN48703
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number48703
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: