Provider Demographics
NPI:1750995130
Name:JOHNSON, LATARSHA MONEK (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LATARSHA
Middle Name:MONEK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 FORD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-8824
Mailing Address - Country:US
Mailing Address - Phone:912-445-6110
Mailing Address - Fax:
Practice Address - Street 1:10200 FORD AVE STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8824
Practice Address - Country:US
Practice Address - Phone:912-445-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN251668363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care