Provider Demographics
NPI:1316196850
Name:WIJEWARDANE, JOHNNIE SUSAN COOPER (PHD, FNP)
Entity Type:Individual
Prefix:DR
First Name:JOHNNIE
Middle Name:SUSAN COOPER
Last Name:WIJEWARDANE
Suffix:
Gender:F
Credentials:PHD, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 CEDAR CREEK LN
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-8488
Mailing Address - Country:US
Mailing Address - Phone:662-312-1021
Mailing Address - Fax:
Practice Address - Street 1:1430 CEDAR CREEK LN
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-8488
Practice Address - Country:US
Practice Address - Phone:662-312-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852708363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04887214Medicaid