Provider Demographics
NPI:1558589614
Name:JOHNIGAN, LEE ETTA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LEE
Middle Name:ETTA
Last Name:JOHNIGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4698 HIGHWAY 145
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-8106
Mailing Address - Country:US
Mailing Address - Phone:601-693-1677
Mailing Address - Fax:
Practice Address - Street 1:4698 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-8106
Practice Address - Country:US
Practice Address - Phone:601-693-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPO74710164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770207OtherPROVIDER NUMBER