Healthcare Provider Details

I. General information

NPI: 1548305501
Provider Name (Legal Business Name): NORMA JEAN JOHNSON BOC ABC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 11/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LAKE DR.
TIPTONVILLE TN
38079-1359
US

IV. Provider business mailing address

140 LAKE DR.
TIPTONVILLE TN
38079-1359
US

V. Phone/Fax

Practice location:
  • Phone: 731-623-4333
  • Fax: 731-623-4333
Mailing address:
  • Phone: 731-623-4333
  • Fax: 731-623-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: