Provider Demographics
NPI:1588798599
Name:JOHNSON, MARI NANETTE (BSN, RN)
Entity Type:Individual
Prefix:MS
First Name:MARI
Middle Name:NANETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 PRAIRIE WATERS DR APT 5113
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5477
Mailing Address - Country:US
Mailing Address - Phone:214-301-9152
Mailing Address - Fax:
Practice Address - Street 1:3651 PRAIRIE WATERS DR APT 5113
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5477
Practice Address - Country:US
Practice Address - Phone:214-301-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX610559163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management