Provider Demographics
NPI:1043478944
Name:JOHNSON, THERESA ANN (PHD, MSHSA, PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, MSHSA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 CHERIE GLEN TRL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1825
Mailing Address - Country:US
Mailing Address - Phone:305-733-9887
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-417-1525
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1719363A00000X
NC0010-01038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant