Provider Demographics
NPI:1922338086
Name:JOHNSON, VICKIE MICHELLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:VICKIE
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 BLUEMONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134
Mailing Address - Country:US
Mailing Address - Phone:901-384-6192
Mailing Address - Fax:901-516-5772
Practice Address - Street 1:3347 BLUEMONT DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-8414
Practice Address - Country:US
Practice Address - Phone:901-384-6192
Practice Address - Fax:901-516-5772
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13530363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health