Provider Demographics
NPI:1457692352
Name:JOHNSON, ANDRAES N (LPN)
Entity Type:Individual
Prefix:MS
First Name:ANDRAES
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 MICHAEL PL
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-5937
Mailing Address - Country:US
Mailing Address - Phone:706-589-6667
Mailing Address - Fax:
Practice Address - Street 1:4130 MICHAEL PL
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-5937
Practice Address - Country:US
Practice Address - Phone:706-589-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-03
Last Update Date:2013-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN63232164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPN63232OtherGEORGIA NURSING BOARD