Provider Demographics
NPI:1417739319
Name:JOHNSON, MARY LEE (PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PRACTITIONER
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PRACTITIONER
Mailing Address - Street 1:5802 BAYOU RAPIDES RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-7728
Mailing Address - Country:US
Mailing Address - Phone:318-730-1861
Mailing Address - Fax:
Practice Address - Street 1:5804 BAYOU RAPIDES RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-7728
Practice Address - Country:US
Practice Address - Phone:318-730-1861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty