Provider Demographics
NPI:1649763236
Name:JOHNSON, LACEY BROOKE (DO)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:21 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2009
Practice Address - Country:US
Practice Address - Phone:770-773-9201
Practice Address - Fax:770-773-9219
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87777207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine