Healthcare Provider Details

I. General information

NPI: 1891467908
Provider Name (Legal Business Name): MATT BRYAN JOHNSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 10TH ST
ANNISTON AL
36207-4716
US

IV. Provider business mailing address

1607 SIBERT DR
GLENCOE AL
35905-9694
US

V. Phone/Fax

Practice location:
  • Phone: 256-235-5121
  • Fax:
Mailing address:
  • Phone: 256-490-7936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-146652
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: