Provider Demographics
NPI:1548680127
Name:JOHNSON, CAROL (NP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 REGENCY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6649
Mailing Address - Country:US
Mailing Address - Phone:770-506-4119
Mailing Address - Fax:770-506-4145
Practice Address - Street 1:105 REGENCY PARK DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6649
Practice Address - Country:US
Practice Address - Phone:770-506-4119
Practice Address - Fax:770-506-4145
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN197812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175478CMedicaid
GA003175478BMedicaid
GA003175478DMedicaid
GA003175478AMedicaid
GA003175478AMedicaid