Provider Demographics
NPI:1669193116
Name:JOHNSON, SAMUEL (CPT, PN1, BCS, CES)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CPT, PN1, BCS, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 STONE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4640
Mailing Address - Country:US
Mailing Address - Phone:615-972-3862
Mailing Address - Fax:
Practice Address - Street 1:5720 STONE BROOK DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4640
Practice Address - Country:US
Practice Address - Phone:615-972-3862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO171400000X
174H00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator