Provider Demographics
NPI:1508308131
Name:JOHNSON, PAULETTE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-7015
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:2100 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2017
Practice Address - Country:US
Practice Address - Phone:870-394-7804
Practice Address - Fax:870-394-7734
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25872363LF0000X
MS901840363LF0000X
AR227301363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS888508OtherMEDICARE MS
TNQ051318Medicaid
MS08527334Medicaid
TNT10930AOtherMEDICARE TN