Healthcare Provider Details

I. General information

NPI: 1023099512
Provider Name (Legal Business Name): AMELIA M JOHNSON DPO
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N MAIN ST SUITE A
SPARTA TN
38583-2055
US

IV. Provider business mailing address

25 N MAIN ST SUITE A
SPARTA TN
38583-2055
US

V. Phone/Fax

Practice location:
  • Phone: 931-836-2235
  • Fax: 931-836-3036
Mailing address:
  • Phone: 931-836-2235
  • Fax: 931-836-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDPO1192
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: