Basic Information
| Provider Information | |||||||||
| NPI: | 1649230152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6350 W A J HWY | ||||||||
| Address2: | DEPARTMENT 100 | ||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 E. WATT STREET | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731616 | ||||||||
| FaxNumber: | 8652731645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000006237 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3341847 | 05 | TN | MEDICAID |