Provider Demographics
NPI:1083944946
Name:JOHNSON, LISA MARIE (LM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 PLEASANT RD # 10748
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-7213
Mailing Address - Country:US
Mailing Address - Phone:704-900-9849
Mailing Address - Fax:704-947-9076
Practice Address - Street 1:2764 PLEASANT RD # 10748
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7213
Practice Address - Country:US
Practice Address - Phone:704-900-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLMW-0043176B00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife