Provider Demographics
NPI:1598422768
Name:JOHNSTON, TRACY LYNN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:JOHNSTON
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 1:3255 11TH AIRBORNE DIV RD
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-4354
Mailing Address - Country:US
Mailing Address - Phone:706-544-9071
Mailing Address - Fax:
Practice Address - Street 1:508 CLARADON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-4354
Practice Address - Country:US
Practice Address - Phone:706-615-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA987654125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist