Provider Demographics
NPI:1396135596
Name:JOHNSON, ELIZABETH (RN)
Entity type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 ASHTON MANOR DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5387
Mailing Address - Country:US
Mailing Address - Phone:301-768-8548
Mailing Address - Fax:
Practice Address - Street 1:553 ASHTON MANOR DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5387
Practice Address - Country:US
Practice Address - Phone:301-768-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN212524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health