Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DPO1192 | TN |
NPI | 1023099512 |
---|---|
Provider Name | Amelia M Johnson |
First Address | Sparta, TN 38583-2055 |
Second Address | Sparta, TN 38583-2055 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4073352 | BLUE CROSS BLUE SHIELD (01) | TN |