Provider Demographics
NPI:1619312998
Name:JOHNSON, TINA CARNEY (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:CARNEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 SAUNDERSVILLE RD
Mailing Address - Street 2:STE 160
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-8903
Mailing Address - Country:US
Mailing Address - Phone:423-458-6267
Mailing Address - Fax:423-790-7136
Practice Address - Street 1:2175 CHAMBLISS AVE NW
Practice Address - Street 2:STE D
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3842
Practice Address - Country:US
Practice Address - Phone:423-472-1140
Practice Address - Fax:423-339-2242
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000529Medicaid
TNQ000529Medicaid