Provider Demographics
NPI:1124293642
Name:JOHNSON, SHAUWNN DAMMEON (PTA)
Entity type:Individual
Prefix:MR
First Name:SHAUWNN
Middle Name:DAMMEON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 LANTERN WOOD DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-6803
Mailing Address - Country:US
Mailing Address - Phone:404-296-6523
Mailing Address - Fax:
Practice Address - Street 1:539 LANTERN WOOD DR
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:GA
Practice Address - Zip Code:30079-6803
Practice Address - Country:US
Practice Address - Phone:404-296-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001866225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant