Provider Demographics
NPI:1306101282
Name:JOHNSON, ANNALYSA M (DO)
Entity type:Individual
Prefix:
First Name:ANNALYSA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANNALYSA
Other - Middle Name:M
Other - Last Name:TENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:270 BMH PHYSICIAN OFFICE BUILDING
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-1532
Mailing Address - Country:US
Mailing Address - Phone:865-546-1642
Mailing Address - Fax:865-681-7949
Practice Address - Street 1:270 BMH PHYSICIANS OFFICE BUILDING
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-3780
Practice Address - Country:US
Practice Address - Phone:865-546-1642
Practice Address - Fax:833-396-2528
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2972207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6167306OtherBCBS
TNQ024129Medicaid