1871604488 NPI number — MRS. JOHNNA KAYE YEALY PA-C

Table of content: MRS. JOHNNA KAYE YEALY PA-C (NPI 1871604488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871604488 NPI number — MRS. JOHNNA KAYE YEALY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YEALY
Provider First Name:
JOHNNA
Provider Middle Name:
KAYE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TANNER
Provider Other First Name:
JOHNNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871604488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2157 IDLEWOOD CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38139-5316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-970-9212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 MADISON AVE
Provider Second Line Business Practice Location Address:
SUITE 890
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-866-8834
Provider Business Practice Location Address Fax Number:
901-302-2834
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  TC 015 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA1377 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA1377 . This is a "TN STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 021074100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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