Healthcare Provider Details

I. General information

NPI: 1194285189
Provider Name (Legal Business Name): KATIE ALYSE JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 SKYLINE DR
JACKSON TN
38301-3938
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP STE 604
JACKSON TN
38305-4403
US

V. Phone/Fax

Practice location:
  • Phone: 731-424-8922
  • Fax: 731-423-2922
Mailing address:
  • Phone: 731-660-7971
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25622
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: