Provider Demographics
NPI:1356637607
Name:JOHNSON, TONYA LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:280 VIRGINIA AVE NE
Practice Address - Street 2:SUITE 103
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273
Practice Address - Country:US
Practice Address - Phone:276-679-2310
Practice Address - Fax:276-679-8460
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00345208600000X
GA71145208600000X
VA0101260566208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVL752B288Medicare PIN