Provider Demographics
NPI:1033420914
Name:JOHNSON, WANDA (BCFNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 411
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-364-2666
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-364-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR586986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily