Provider Demographics
NPI:1972031227
Name:JOHNSON, RACHEL (CRNA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-4159
Mailing Address - Country:US
Mailing Address - Phone:601-444-9266
Mailing Address - Fax:601-444-9267
Practice Address - Street 1:101 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2021
Practice Address - Country:US
Practice Address - Phone:601-827-5075
Practice Address - Fax:601-827-5133
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904536363LF0000X
MS901435367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02906069Medicaid