Provider Demographics
NPI:1871604488
Name:YEALY, JOHNNA KAYE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JOHNNA
Middle Name:KAYE
Last Name:YEALY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JOHNNA
Other - Middle Name:
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2157 IDLEWOOD CV
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-5316
Mailing Address - Country:US
Mailing Address - Phone:615-970-9212
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE
Practice Address - Street 2:SUITE 890
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3410
Practice Address - Country:US
Practice Address - Phone:901-866-8834
Practice Address - Fax:901-302-2834
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC 015363A00000X
TNPA1377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA1377OtherTN STATE LICENSE
TN10397I8623Medicare PIN