Provider Demographics
NPI:1477501088
Name:JOHNSON-WYATT, PAULA (OD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:
Last Name:JOHNSON-WYATT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:222 SPRINGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6238
Mailing Address - Country:US
Mailing Address - Phone:731-423-1724
Mailing Address - Fax:
Practice Address - Street 1:1012 GREYSTONE SQUARE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-660-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT-2423152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU86221Medicare UPIN