Healthcare Provider Details

I. General information

NPI: 1154213460
Provider Name (Legal Business Name): MARISA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISA NORWOOD RN

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 GREENWOOD AVE
CLARKSVILLE TN
37040-4068
US

IV. Provider business mailing address

401 VICTORY RD APT 1N
CLARKSVILLE TN
37042-2948
US

V. Phone/Fax

Practice location:
  • Phone: 888-277-4137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number0001318711
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: