Provider Demographics
NPI:1295754596
Name:JOHNSON, PRINCESSA (MD)
Entity type:Individual
Prefix:
First Name:PRINCESSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PARK PLACE CT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6052
Mailing Address - Country:US
Mailing Address - Phone:706-736-6181
Mailing Address - Fax:
Practice Address - Street 1:2803 WRIGHTSBORO RD
Practice Address - Street 2:SUITE 45
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-3913
Practice Address - Country:US
Practice Address - Phone:706-736-2737
Practice Address - Fax:706-731-9047
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist