Provider Demographics
NPI:1912468596
Name:JOHNSON, VICKIE ANTIONETTE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:ANTIONETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 VILLA NOVA ST
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840-6221
Mailing Address - Country:US
Mailing Address - Phone:229-366-0906
Mailing Address - Fax:229-732-5561
Practice Address - Street 1:90 VILLA NOVA ST
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-6221
Practice Address - Country:US
Practice Address - Phone:229-366-0906
Practice Address - Fax:229-732-5561
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator