Provider Demographics
NPI:1790180131
Name:JOHNSON, JOHNNY L (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 CAMBELLTON RD SUITE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 CAMBELTON RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311
Practice Address - Country:US
Practice Address - Phone:404-629-3539
Practice Address - Fax:404-629-0699
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist