Basic Information
| Provider Information | |||||||||
| NPI: | 1972564102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | NATIONS | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 20 COLLINS DR STE B | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301208533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 COLLINS DR STE B | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301208533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 172752 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | RN139381 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 336125 | 01 | GA | WELLCARE ID NUMBER | OTHER | 000861627C | 01 | GA | PEACH STATE ID | OTHER | 5261615 | 01 | GA | CIGNA | OTHER | 598970 | 01 | GA | BCBS | OTHER | 000861627C | 05 | GA | MEDICAID | 049906810 | 01 | GA | CHAMPUS TRICARE | OTHER | 10057735 | 01 | GA | AMERIGROUP | OTHER |