Provider Demographics
NPI:1245639830
Name:JOHNSON, RAEANNE TATEM (RN,MSN,CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:RAEANNE
Middle Name:TATEM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN,MSN,CPNP-PC
Other - Prefix:MS
Other - First Name:RAEANNE
Other - Middle Name:SAVAGE
Other - Last Name:TATEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:260 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4922
Mailing Address - Country:US
Mailing Address - Phone:919-488-0015
Mailing Address - Fax:919-277-0066
Practice Address - Street 1:1005 BIG OAK CT
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6565
Practice Address - Country:US
Practice Address - Phone:919-266-5669
Practice Address - Fax:919-488-1717
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007103363LP0200X
NC202273752080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics