Provider Demographics
NPI:1144639519
Name:JOHNSON, TAMMY L (FNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
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:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:10650 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9611
Practice Address - Country:US
Practice Address - Phone:606-408-7337
Practice Address - Fax:606-408-6349
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008814363LF0000X
OHCOA.16361-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810028389Medicaid
KY7100408100Medicaid
OH0115926Medicaid
OHH430750Medicare PIN
OH0115926Medicaid