Provider Demographics
NPI:1184488355
Name:JOHNSON, GEORGETTE R
Entity type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:R
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 1:401 REVIS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6339
Mailing Address - Country:US
Mailing Address - Phone:864-907-7627
Mailing Address - Fax:
Practice Address - Street 1:120 RENAISSANCE CIR STE 1
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2459
Practice Address - Country:US
Practice Address - Phone:864-907-7627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC205384163W00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No163W00000XNursing Service ProvidersRegistered Nurse