Provider Demographics
NPI:1689652919
Name:JOHNSON, ETHNEY LETETIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ETHNEY
Middle Name:LETETIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 SHADOW LAKES DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6298
Mailing Address - Country:US
Mailing Address - Phone:770-498-5917
Mailing Address - Fax:
Practice Address - Street 1:2385 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-3446
Practice Address - Country:US
Practice Address - Phone:678-530-6012
Practice Address - Fax:678-530-6130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN111272163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice