Provider Demographics
NPI:1114387032
Name:JOHNSON, DESIREA
Entity Type:Individual
Prefix:
First Name:DESIREA
Middle Name:
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 1:4788 CHAFIN POINT CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-3375
Mailing Address - Country:US
Mailing Address - Phone:678-793-5245
Mailing Address - Fax:
Practice Address - Street 1:4788 CHAFIN POINT CT
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-3375
Practice Address - Country:US
Practice Address - Phone:678-793-5245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN069758164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse