Provider Demographics
NPI:1619239373
Name:JOHNSON, TINA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6275
Mailing Address - Country:US
Mailing Address - Phone:318-352-7768
Mailing Address - Fax:318-357-3661
Practice Address - Street 1:1029 KEYSER AVE STE A
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6215
Practice Address - Country:US
Practice Address - Phone:318-352-7768
Practice Address - Fax:318-357-3661
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP06853OtherAPRN LICENSE