Basic Information
| Provider Information | |||||||||
| NPI: | 1548681315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVIN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERKINS | ||||||||
| OtherFirstName: | DAVIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015457302 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 PERES AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381081660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015155500 | ||||||||
| FaxNumber: | 9014582491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2013 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 0000017584 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.