Provider Demographics
NPI:1831997121
Name:JOHNSON, CARELLE
Entity type:Individual
Prefix:MRS
First Name:CARELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CARELLE
Other - Middle Name:
Other - Last Name:OVERSTREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA, CMA
Mailing Address - Street 1:158 KIOWA DR S
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545
Mailing Address - Country:US
Mailing Address - Phone:912-424-3204
Mailing Address - Fax:
Practice Address - Street 1:158 KIOWA DR S
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545
Practice Address - Country:US
Practice Address - Phone:912-424-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0036020198311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility