Provider Demographics
NPI:1023099512
Name:JOHNSON, AMELIA M (DPO)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-2055
Mailing Address - Country:US
Mailing Address - Phone:931-836-2235
Mailing Address - Fax:931-836-3036
Practice Address - Street 1:25 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-2055
Practice Address - Country:US
Practice Address - Phone:931-836-2235
Practice Address - Fax:931-836-3036
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO1192156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4073352OtherBLUE CROSS BLUE SHIELD
TN4970570001Medicare NSC