Provider Demographics
NPI:1205207388
Name:JOHNSON, DENETRA
Entity Type:Individual
Prefix:
First Name:DENETRA
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 1:3730 CARMIA DR SW
Mailing Address - Street 2:STE 110-130
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-6258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3730 CARMIA DR SW
Practice Address - Street 2:STE 110-130
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-6258
Practice Address - Country:US
Practice Address - Phone:404-344-7286
Practice Address - Fax:404-344-1310
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865978363LF0000X
GARN161105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN161105OtherLICENSE