Provider Demographics
NPI:1306977814
Name:JOHNSON, MALINDA A (PA)
Entity type:Individual
Prefix:MRS
First Name:MALINDA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:5801 CROSSINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3130
Mailing Address - Country:US
Mailing Address - Phone:615-941-8501
Mailing Address - Fax:615-941-8102
Practice Address - Street 1:5801 CROSSINGS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3130
Practice Address - Country:US
Practice Address - Phone:615-941-8501
Practice Address - Fax:615-941-8102
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1043363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1043OtherSTATE LICENSE
MJ0960751OtherFEDERAL DEA CERTIFICATE