Healthcare Provider Details

I. General information

NPI: 1427666460
Provider Name (Legal Business Name): JOHNNY DWAYNE FRALEY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W RAVINE RD
KINGSPORT TN
37660
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-224-4000
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179740
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32564
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: