Provider Demographics
NPI:1306235312
Name:JOHNSON, CLAUDETTE ANGELLA
Entity type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:ANGELLA
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 1:814 ARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8028
Mailing Address - Country:US
Mailing Address - Phone:678-615-2677
Mailing Address - Fax:
Practice Address - Street 1:2296 HENDERSON MILL RD NE STE 116
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2739
Practice Address - Country:US
Practice Address - Phone:404-692-6907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily