Provider Demographics
NPI:1710860432
Name:JOHNSON, MARYELLEN (FNP)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 TUSCULUM BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4066
Mailing Address - Country:US
Mailing Address - Phone:423-922-9224
Mailing Address - Fax:423-922-9939
Practice Address - Street 1:906 TUSCULUM BLVD STE 1
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4066
Practice Address - Country:US
Practice Address - Phone:423-922-9224
Practice Address - Fax:423-922-9939
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily