Provider Demographics
NPI:1427556349
Name:JOHNSON, CANDACE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:62 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-544-4550
Practice Address - Fax:601-582-3373
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902209363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health