Healthcare Provider Details

I. General information

NPI: 1508181090
Provider Name (Legal Business Name): KATHERINE HALEY JOHNSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8040 WOLF RIVER BLVD STE 102
MEMPHIS TN
38138-1773
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 901-227-7900
  • Fax: 901-227-7920
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: