Individual
MARY P. JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-2005
(601) 703-9920
Mailing address
504 CLINTON CENTER DRIVE, CBO - SUITE 4300, CLINTON, MS 39056
(601) 496-9794
(601) 815-0434
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R864870
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00125198
—
MS
01
—
430070545
RAILROAD MEDICARE
—
Enumeration date
11/15/2005
Last updated
05/14/2021
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