Provider Demographics
NPI:1881862159
Name:JOHNSON, ARDENA
Entity Type:Individual
Prefix:
First Name:ARDENA
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 1:60 LIGHTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1916
Mailing Address - Country:US
Mailing Address - Phone:678-467-2778
Mailing Address - Fax:
Practice Address - Street 1:60 LIGHTWOOD DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016
Practice Address - Country:US
Practice Address - Phone:678-467-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA102164303CMedicaid