Provider Demographics
NPI:1689454852
Name:JOHNSON, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-8802
Mailing Address - Country:US
Mailing Address - Phone:769-285-4579
Mailing Address - Fax:
Practice Address - Street 1:114 JEFFERSON DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5104
Practice Address - Country:US
Practice Address - Phone:601-653-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPH4296171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator