Basic Information
| Provider Information | |||||||||
| NPI: | 1740938018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46 LYNWOOD ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383511316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316020757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315417070 | ||||||||
| FaxNumber: | 7315417075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 31745 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.