Basic Information
| Provider Information | |||||||||
| NPI: | 1194092692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4156 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378024156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 MORNING POINT DR | ||||||||
| Address2: | |||||||||
| City: | LENOIR CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377726447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652719966 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APN0000016191 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1527764 | 05 | TN | MEDICAID |