Provider Demographics
NPI:1710116769
Name:JOHNSON, NICOLE TAMARA (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:TAMARA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 CAMERON PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7816
Mailing Address - Country:US
Mailing Address - Phone:770-996-6446
Mailing Address - Fax:770-996-6279
Practice Address - Street 1:3580 CAMERON PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7816
Practice Address - Country:US
Practice Address - Phone:770-996-6446
Practice Address - Fax:770-996-6279
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN179949363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health