Provider Demographics
NPI:1750402731
Name:JOHNSON, NIKKIA F (MD)
Entity type:Individual
Prefix:DR
First Name:NIKKIA
Middle Name:F
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NIKKIA
Other - Middle Name:F
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:39 KENT RD STE 5
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1697
Mailing Address - Country:US
Mailing Address - Phone:229-353-7337
Mailing Address - Fax:229-391-4051
Practice Address - Street 1:39 KENT RD STE 5
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1697
Practice Address - Country:US
Practice Address - Phone:229-353-7337
Practice Address - Fax:229-391-4051
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA459384605AMedicaid
GA459384605AMedicaid