Healthcare Provider Details

I. General information

NPI: 1457644254
Provider Name (Legal Business Name): MRS. MEGAN D JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 W ELK AVE SUITE 21
ELIZABETHTON TN
37643-2895
US

IV. Provider business mailing address

1497 W ELK AVE SUITE 21
ELIZABETHTON TN
37643-2895
US

V. Phone/Fax

Practice location:
  • Phone: 423-542-7420
  • Fax: 423-542-7425
Mailing address:
  • Phone: 423-542-7420
  • Fax: 423-542-7425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51290
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: