Provider Demographics
NPI:1598389272
Name:JOHNSON, MARY (PMHNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-2531
Mailing Address - Country:US
Mailing Address - Phone:318-728-5488
Mailing Address - Fax:
Practice Address - Street 1:307 HAYES ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-2531
Practice Address - Country:US
Practice Address - Phone:318-728-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208805363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health