Provider Demographics
NPI:1669975587
Name:JOHNSON, CAROLYN S (FNP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:CAROLYN
Other - Middle Name:S
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1027 FRENCH RD
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-9605
Mailing Address - Country:US
Mailing Address - Phone:662-466-0330
Mailing Address - Fax:662-756-0931
Practice Address - Street 1:1027 FRENCH RD
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-9605
Practice Address - Country:US
Practice Address - Phone:662-466-0330
Practice Address - Fax:662-756-0931
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR800714163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice