Provider Demographics
NPI:1871923771
Name:JOHNSON, TAWANDA (FNP-BC)
Entity type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-3248
Mailing Address - Country:US
Mailing Address - Phone:662-332-6150
Mailing Address - Fax:
Practice Address - Street 1:15055 COLLECTION CENTER DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60693-0150
Practice Address - Country:US
Practice Address - Phone:256-383-3325
Practice Address - Fax:256-383-5911
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02602740Medicaid