Basic Information
Provider Information | |||||||||
NPI: | 1841611852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | HANNAH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUSH | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: | HANNAH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 STONEFOREST DR STE 130 | ||||||||
Address2: |   | ||||||||
City: | WOODSTOCK | ||||||||
State: | GA | ||||||||
PostalCode: | 301894881 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783881621 | ||||||||
FaxNumber: | 6783915099 | ||||||||
Practice Location | |||||||||
Address1: | 61 WHITCHER ST STE 2100 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704230595 | ||||||||
FaxNumber: | 6783915055 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2013 | ||||||||
LastUpdateDate: | 04/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 7075 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.