Provider Demographics
NPI:1124555115
Name:JOHNSON, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
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 1:213 WINCHESTER TRL SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-1334
Mailing Address - Country:US
Mailing Address - Phone:513-919-7600
Mailing Address - Fax:
Practice Address - Street 1:2400 HERODIAN WAY SE STE 375
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8581
Practice Address - Country:US
Practice Address - Phone:513-919-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management