Provider Demographics
NPI:1033249081
Name:JOHNSTON, MARIA LANA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:LANA
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OLD COUNTRY CLUB RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-7931
Mailing Address - Country:US
Mailing Address - Phone:478-414-1986
Mailing Address - Fax:
Practice Address - Street 1:107 SPORTSMAN CLUB RD NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-8787
Practice Address - Country:US
Practice Address - Phone:478-453-0041
Practice Address - Fax:478-453-3498
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCWFMedicare ID - Type UnspecifiedPROVIDER NUMBER