Provider Demographics
NPI:1053913392
Name:JOHNSON, NANCY MOORE (PMHNP STUDENT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:MOORE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 GOV HOGG DR
Mailing Address - Street 2:
Mailing Address - City:POINTBLANK
Mailing Address - State:TX
Mailing Address - Zip Code:77364-6779
Mailing Address - Country:US
Mailing Address - Phone:936-581-1819
Mailing Address - Fax:
Practice Address - Street 1:281 GOV HOGG DR
Practice Address - Street 2:
Practice Address - City:POINTBLANK
Practice Address - State:TX
Practice Address - Zip Code:77364-6779
Practice Address - Country:US
Practice Address - Phone:936-581-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX581469363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health