Healthcare Provider Details

I. General information

NPI: 1477501088
Provider Name (Legal Business Name): PAULA JOHNSON-WYATT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAULA JOHNSON O.D.

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 GREYSTONE SQUARE
JACKSON TN
38305
US

IV. Provider business mailing address

222 SPRINGVIEW DR
JACKSON TN
38305-6238
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-1100
  • Fax:
Mailing address:
  • Phone: 731-423-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberODT-2423
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: