Provider Demographics
NPI:1689800997
Name:JOHNSON, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:JOHNSON
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 1:6004 SUSAN CIR APT A
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3278 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY A F B
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-527-2105
Practice Address - Fax:229-257-3113
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians