Basic Information
| Provider Information | |||||||||
| NPI: | 1043290307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705353611 | ||||||||
| FaxNumber: | 7705357092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036403 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 302578 | 01 | GA | WELLCARE | OTHER | 4360675 | 01 | GA | AETNA | OTHER | 302577 | 01 | GA | WELLCARE | OTHER | 317570 | 01 | GA | CIGNA | OTHER | 302566 | 01 | GA | WELLCARE | OTHER | 302576 | 01 | GA | WELLCARE | OTHER | 1201604 | 01 | GA | UNITED HEALTHCARE | OTHER | 000532298R | 05 | GA | MEDICAID | 000532298S | 05 | GA | MEDICAID | 000532298P | 05 | GA | MEDICAID | 000532298Q | 05 | GA | MEDICAID | 10033001 | 01 | GA | AMERIGROUP | OTHER | 000532298N | 05 | GA | MEDICAID | 52450432 | 01 | GA | BCBS | OTHER |