Provider Demographics
NPI:1285233452
Name:JOHNSON, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 ALLYSON GENE CV
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-7359
Mailing Address - Country:US
Mailing Address - Phone:901-289-7903
Mailing Address - Fax:
Practice Address - Street 1:2808 ALLYSON GENE CV
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611-7359
Practice Address - Country:US
Practice Address - Phone:901-289-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty