Provider Demographics
NPI:1811603921
Name:JOHNSON, MARY ELIZABETH (WHNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 SHILOH RUN DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-8758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 STONE CREEK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8210
Practice Address - Country:US
Practice Address - Phone:601-822-2294
Practice Address - Fax:601-793-4273
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS918717163W00000X
MS906992363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse