Provider Demographics
NPI:1114102050
Name:JOHNSON, ALICE JEANETTE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:JEANETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 E NORTHFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-1204
Mailing Address - Country:US
Mailing Address - Phone:615-890-3471
Mailing Address - Fax:
Practice Address - Street 1:931 E NORTHFIELD BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-1204
Practice Address - Country:US
Practice Address - Phone:615-890-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0187930OtherBCBS
TN1450521Medicaid
TN1450521Medicaid