Provider Demographics
NPI:1912905464
Name:JOHNSON, MAE D (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MAE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MEMORIAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-226-3139
Mailing Address - Fax:706-278-6606
Practice Address - Street 1:1107 MEMORIAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-226-3139
Practice Address - Fax:706-278-6606
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN027354163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000670326BMedicaid
GA50BBBXKMedicare PIN
R98877Medicare UPIN