Individual
ILLISIA MARIE JOHNSTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP-C
Contact information
Practice address
1008 N 15TH AVE, LAUREL, MS 39440-2656
(601) 426-5125
Mailing address
PO BOX 247, LAUREL, MS 39441-0247
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
F06212134
MS
Other
Enumeration date
06/28/2021
Last updated
10/03/2024
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