Basic Information
| Provider Information | |||||||||
| NPI: | 1104809508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BOB WALLACE AVE SW | ||||||||
| Address2: | SUITE E | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565395339 | ||||||||
| FaxNumber: | 2565365111 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 BOB WALLACE AVE SW | ||||||||
| Address2: | SUITE E | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565395339 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4556 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | AL4556 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 51518176 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 4483860 | 01 | AL | AETNA | OTHER | 51010283 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 529702470 | 05 | AL | MEDICAID | 1403382 | 01 | AL | FIRST HEALTH | OTHER |