Provider Demographics
NPI:1295432870
Name:JOHNSON, KEYANA
Entity type:Individual
Prefix:
First Name:KEYANA
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 1:6022 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-2902
Mailing Address - Country:US
Mailing Address - Phone:706-888-0908
Mailing Address - Fax:
Practice Address - Street 1:6022 CARIBOU DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2902
Practice Address - Country:US
Practice Address - Phone:706-888-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058640110172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA92-1825334OtherNON EMERGENCY MEDICAL TRANSPORTATION