Basic Information
| Provider Information | |||||||||
| NPI: | 1073578456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220213 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 2863 HIGHWAY 45 BYP | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220213 | ||||||||
| FaxNumber: | 7316608369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 49323 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | 207PP0204X | DR.0049323 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | INPROCESS | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD63332 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.