Healthcare Provider Details

I. General information

NPI: 1144970781
Provider Name (Legal Business Name): ANNA VIMALA JOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 S HIGHWAY 25 W
WILLIAMSBURG KY
40769-1639
US

IV. Provider business mailing address

PO BOX 540
JELLICO TN
37762-0540
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2656
  • Fax:
Mailing address:
  • Phone: 423-784-8492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73817
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60344
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: