Provider Demographics
NPI:1023476447
Name:JOHNSON, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 WINFIELD DUNN PKWY
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37876-5511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 WINFIELD DUNN PKWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37876-5511
Practice Address - Country:US
Practice Address - Phone:865-429-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000039714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist