Healthcare Provider Details

I. General information

NPI: 1619242187
Provider Name (Legal Business Name): TARA TYLER JOHNSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2012
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 TROTWOOD AVE
COLUMBIA TN
38401-4802
US

IV. Provider business mailing address

1224 TROTWOOD AVE
COLUMBIA TN
38401-4802
US

V. Phone/Fax

Practice location:
  • Phone: 931-381-1111
  • Fax:
Mailing address:
  • Phone: 931-381-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011020238
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: