Healthcare Provider Details

I. General information

NPI: 1821306259
Provider Name (Legal Business Name): SUSAN AYERS JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 BROAD ST
BAXTER TN
38544-5117
US

IV. Provider business mailing address

1729 E SPRING ST
COOKEVILLE TN
38506-4320
US

V. Phone/Fax

Practice location:
  • Phone: 931-858-2116
  • Fax:
Mailing address:
  • Phone: 931-858-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7710
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: