Basic Information
| Provider Information | |||||||||
| NPI: | 1578573762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 DEER CREEK DR | ||||||||
| Address2: | |||||||||
| City: | FORSYTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310296549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789948581 | ||||||||
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| Practice Location | |||||||||
| Address1: | 657 HEMLOCK ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | RN052724 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 383672674A | 05 | GA | MEDICAID |