Provider Demographics
NPI:1801353081
Name:JOHNSON, MALLORY HARRIS (CRNA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:HARRIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:BRIELLE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 116111
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6111
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-279-1660
Practice Address - Street 1:3100 KEMBLE AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4211
Practice Address - Country:US
Practice Address - Phone:334-279-1450
Practice Address - Fax:334-279-1660
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239579367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered