Basic Information
| Provider Information | |||||||||
| NPI: | 1144546516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LAVERN | ||||||||
| MiddleName: | BANKS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E EH CRUMP BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381265394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012612000 | ||||||||
| FaxNumber: | 9019469262 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E EH CRUMP BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381265310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012612000 | ||||||||
| FaxNumber: | 9019469262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2010 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 20905 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03472033 | 05 | MS | MEDICAID | Q032334 | 05 | TN | MEDICAID | 20905 | 01 | TN | TN LICENSE | OTHER | 6129052 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | N1725089 | 01 | TN | WELLCARE | OTHER |