Provider Demographics
NPI:1629601711
Name:JOHNSON, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:4006 PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5025
Mailing Address - Country:US
Mailing Address - Phone:931-698-6519
Mailing Address - Fax:
Practice Address - Street 1:110 KITTRELL ST
Practice Address - Street 2:
Practice Address - City:HOHENWALD
Practice Address - State:TN
Practice Address - Zip Code:38462-1363
Practice Address - Country:US
Practice Address - Phone:931-295-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNF12190969363LF0000X
TN34085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily