Provider Demographics
NPI:1821470733
Name:JOHNSON, MOLLY (APRN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 STILLWATER DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9119
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:870-932-3611
Practice Address - Street 1:800 S CHURCH ST STE 400
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4112
Practice Address - Country:US
Practice Address - Phone:870-935-6012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR096554163W00000X
ARA005817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229158758Medicaid