Basic Information
| Provider Information | |||||||||
| NPI: | 1376855080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | QUINETTA | ||||||||
| MiddleName: | BRIGETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVENUE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015456286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 E MAXWELL ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405082678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593230005 | ||||||||
| FaxNumber: | 8593230790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301097155 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 49124 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VM0101X | 59709 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 49124 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
No ID Information.