Provider Demographics
NPI:1285636407
Name:JOHNSON, REBECCA A (FNP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:MISJA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, BC
Mailing Address - Street 1:836 CONSTELLATION DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2811
Mailing Address - Country:US
Mailing Address - Phone:434-258-6517
Mailing Address - Fax:
Practice Address - Street 1:836 CONSTELLATION DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2811
Practice Address - Country:US
Practice Address - Phone:434-258-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024095207363LF0000X
PASP01065363LF0000X
GA291053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
010217822OtherVA PREMIER PROVIDER NUMBE
203639329004OtherTRICARE PROVIDER NUMBER
VA010217822Medicaid
203639329004OtherTRICARE PROVIDER NUMBER
VA00W826C18Medicare ID - Type Unspecified