Provider Demographics
NPI:1639535503
Name:JOHNSON, ALICIA KAY
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 N MAIN ST NW STE 12
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2756
Mailing Address - Country:US
Mailing Address - Phone:470-315-0055
Mailing Address - Fax:888-838-5376
Practice Address - Street 1:3070 N MAIN ST NW STE 12
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2756
Practice Address - Country:US
Practice Address - Phone:470-315-0055
Practice Address - Fax:888-838-5376
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME211280363LP0808X
UT11723625-4405363LP0808X
OR20210293NP-PP363LP0808X
RIAPRN02540363LP0808X
NV855120363LP0808X
VT101.0135557TELE363LP0808X
ID67513363LP0808X
NH086000-23363LP0808X
GARN216448363LP0808X
GA216448363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health