Provider Demographics
NPI:1942871579
Name:JOHNSON, MICHIKO WANATESHE
Entity Type:Individual
Prefix:MISS
First Name:MICHIKO
Middle Name:WANATESHE
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 1:190 BOWEN RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1812
Mailing Address - Country:US
Mailing Address - Phone:678-939-8625
Mailing Address - Fax:
Practice Address - Street 1:190 BOWEN RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-1812
Practice Address - Country:US
Practice Address - Phone:678-939-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA863355445343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)