Healthcare Provider Details

I. General information

NPI: 1457769978
Provider Name (Legal Business Name): JOSHUA BRENT JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2341 MCCALLIE AVE STE 402
CHATTANOOGA TN
37404-3231
US

IV. Provider business mailing address

255 ACORN OAKS CIR APT 341
CHATTANOOGA TN
37405-2088
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-3309
  • Fax:
Mailing address:
  • Phone: 812-480-1427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number186662
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN19125T
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28181730A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: