Provider Demographics
NPI:1598068892
Name:JOHNSON, STEPHEN D (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 WEDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6366
Mailing Address - Country:US
Mailing Address - Phone:601-665-4355
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02335251Medicaid
MS02335251Medicaid