Provider Demographics
NPI:1003679804
Name:JOHNSON, RAESHAUNA (NP)
Entity type:Individual
Prefix:MRS
First Name:RAESHAUNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WILD BERRY PL
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-5653
Mailing Address - Country:US
Mailing Address - Phone:501-478-1504
Mailing Address - Fax:
Practice Address - Street 1:8 WILD BERRY PL
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-5653
Practice Address - Country:US
Practice Address - Phone:501-478-1504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR227318363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care