Provider Demographics
NPI:1881204758
Name:WINDELL JOHNSON, P. A.
Entity Type:Organization
Organization Name:WINDELL JOHNSON, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MR
Authorized Official - First Name:WINDELL
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:APRN
Authorized Official - Phone:501-618-5317
Mailing Address - Street 1:3 RACCOON CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4929
Mailing Address - Country:US
Mailing Address - Phone:501-618-5317
Mailing Address - Fax:
Practice Address - Street 1:1401 S STATE ST STE C
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-5827
Practice Address - Country:US
Practice Address - Phone:870-534-5523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty