Provider Demographics
NPI:1699502971
Name:JOHNSON, AUDRA DENISE
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 BAY HOLLOW CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2601
Mailing Address - Country:US
Mailing Address - Phone:901-347-9203
Mailing Address - Fax:
Practice Address - Street 1:5405 FOX PLAZA DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-1518
Practice Address - Country:US
Practice Address - Phone:901-491-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN937308246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy