Provider Demographics
NPI:1265170856
Name:JOHNSON, CAMERON DEWAYNE
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:DEWAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 COACH DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3372
Mailing Address - Country:US
Mailing Address - Phone:423-290-3980
Mailing Address - Fax:
Practice Address - Street 1:1755 GUNBARREL RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7137
Practice Address - Country:US
Practice Address - Phone:423-680-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN205373163WE0003X
TN31966363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency