Provider Demographics
NPI:1598103319
Name:JOHNSON, SALLIE (RN)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 WAGON WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-1444
Mailing Address - Country:US
Mailing Address - Phone:770-389-0487
Mailing Address - Fax:
Practice Address - Street 1:194 WAGON WHEEL DR
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-1444
Practice Address - Country:US
Practice Address - Phone:770-389-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN12135164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse