Provider Demographics
NPI:1558904565
Name:JOHNSON, CARLA FUNK (RN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:FUNK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:CARLA
Other - Middle Name:FUNK
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:SALTERS
Mailing Address - State:SC
Mailing Address - Zip Code:29590-0064
Mailing Address - Country:US
Mailing Address - Phone:843-312-0209
Mailing Address - Fax:
Practice Address - Street 1:191 OLD GAPWAY ROAD
Practice Address - Street 2:
Practice Address - City:SALTERS
Practice Address - State:SC
Practice Address - Zip Code:29590-0064
Practice Address - Country:US
Practice Address - Phone:843-312-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC236349364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist