Provider Demographics
NPI:1508241589
Name:JOHNSON, PAMMIE WILSON
Entity Type:Individual
Prefix:MRS
First Name:PAMMIE
Middle Name:WILSON
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 1:915 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8342
Mailing Address - Country:US
Mailing Address - Phone:318-449-5210
Mailing Address - Fax:318-449-5206
Practice Address - Street 1:915 3RD ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8342
Practice Address - Country:US
Practice Address - Phone:318-449-5210
Practice Address - Fax:318-449-5206
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily