Provider Demographics
NPI:1265218663
Name:JOHNSON, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
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 1:3437 N DRUID HILLS RD APT I
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3721
Mailing Address - Country:US
Mailing Address - Phone:718-801-3653
Mailing Address - Fax:
Practice Address - Street 1:3330 CUMBERLAND BLVD SE STE 2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5995
Practice Address - Country:US
Practice Address - Phone:718-801-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program