Provider Demographics
NPI:1194425272
Name:JOHNSON, KWEZETA
Entity type:Individual
Prefix:
First Name:KWEZETA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 ARKWRIGHT RD APT 79
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1727
Mailing Address - Country:US
Mailing Address - Phone:478-258-5618
Mailing Address - Fax:
Practice Address - Street 1:4150 ARKWRIGHT RD APT 79
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1727
Practice Address - Country:US
Practice Address - Phone:478-258-5618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 332100000X, 347C00000X
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No347C00000XTransportation ServicesPrivate Vehicle