Provider Demographics
NPI:1699851634
Name:JOHNSON, MARY ANN (CFNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0283
Mailing Address - Country:US
Mailing Address - Phone:601-405-4399
Mailing Address - Fax:601-405-4399
Practice Address - Street 1:1883 HIGHWAY 43 S
Practice Address - Street 2:SUITE E
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8405
Practice Address - Country:US
Practice Address - Phone:601-407-1137
Practice Address - Fax:601-407-1137
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR688916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124595Medicaid
MS00124595Medicaid