Provider Demographics
NPI:1568643567
Name:JOHNSON, NICOLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:FRANCES
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:5905 OLD DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9173
Mailing Address - Country:US
Mailing Address - Phone:229-869-6625
Mailing Address - Fax:
Practice Address - Street 1:5905 OLD DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-9173
Practice Address - Country:US
Practice Address - Phone:229-869-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-18
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002150225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant