Provider Demographics
NPI:1891154092
Name:JOHNSON, MARY BETH (AGACNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4308
Mailing Address - Country:US
Mailing Address - Phone:865-373-7100
Mailing Address - Fax:
Practice Address - Street 1:9330 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4308
Practice Address - Country:US
Practice Address - Phone:865-373-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN020752363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care