Provider Demographics
NPI:1275619108
Name:JOHNSON, MARY ALICE (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 3RD AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1985
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:
Practice Address - Street 1:425 W 3RD AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1941
Practice Address - Country:US
Practice Address - Phone:229-312-7050
Practice Address - Fax:229-312-7055
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN120782164W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse