Healthcare Provider Details

I. General information

NPI: 1962107557
Provider Name (Legal Business Name): ELLIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 MONTROSE RD
MOUNTAIN BRK AL
35213-3832
US

IV. Provider business mailing address

PO BOX 5474
MARYVILLE TN
37802-5474
US

V. Phone/Fax

Practice location:
  • Phone: 205-871-3583
  • Fax:
Mailing address:
  • Phone: 865-661-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: