Individual
IDA JOHNICAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
491 S SANGA RD, CORDOVA, TN 38018-7686
(901) 230-4309
Mailing address
491 S SANGA RD, CORDOVA, TN 38018-7686
(901) 230-4309
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Enumeration date
08/28/2020
Last updated
08/28/2020
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