Healthcare Provider Details

I. General information

NPI: 1407735053
Provider Name (Legal Business Name): CALLIE LYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 WILSON AVE
LOUISVILLE KY
40211-1969
US

IV. Provider business mailing address

125 MOUNTAIN VIEW DR
RICKMAN TN
38580-2057
US

V. Phone/Fax

Practice location:
  • Phone: 502-774-4401
  • Fax: 833-471-2827
Mailing address:
  • Phone: 931-704-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: