Provider Demographics
NPI:1538898911
Name:JOHNSON, TONDRA LYNETTE
Entity type:Individual
Prefix:
First Name:TONDRA
Middle Name:LYNETTE
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 1:2848 FAWNWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4105
Mailing Address - Country:US
Mailing Address - Phone:229-305-7978
Mailing Address - Fax:
Practice Address - Street 1:2848 FAWNWOOD CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-4105
Practice Address - Country:US
Practice Address - Phone:229-305-7978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002685224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant