Provider Demographics
NPI:1205602125
Name:JOHNSON, MARISSA (NBC-WHC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NBC-WHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 CHERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6239
Mailing Address - Country:US
Mailing Address - Phone:256-770-2550
Mailing Address - Fax:
Practice Address - Street 1:888 CHERRY BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6239
Practice Address - Country:US
Practice Address - Phone:256-770-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA3630981171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach