Provider Demographics
NPI:1043290307
Name:JOHNSON, NANCY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-535-3611
Practice Address - Fax:770-535-7092
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036403208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA302578OtherWELLCARE
GA4360675OtherAETNA
GA302577OtherWELLCARE
GA317570OtherCIGNA
GA302566OtherWELLCARE
GA302576OtherWELLCARE
GA1201604OtherUNITED HEALTHCARE
GA000532298RMedicaid
GA000532298SMedicaid
GA000532298PMedicaid
GA000532298QMedicaid
GA10033001OtherAMERIGROUP
GA000532298NMedicaid
GA52450432OtherBCBS
GA302566OtherWELLCARE
GA000532298RMedicaid