Provider Demographics
NPI:1356862270
Name:JOHNSON, CARRIE FAYE (NP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:FAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:FAYE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1431 DALZELL STREET
Mailing Address - Street 2:MANAGED CARE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3709
Mailing Address - Country:US
Mailing Address - Phone:318-626-0284
Mailing Address - Fax:318-629-4779
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-212-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily