Provider Demographics
NPI:1447332275
Name:JOHNSON, TRACIE BAKER (LPN)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:BAKER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-0436
Mailing Address - Country:US
Mailing Address - Phone:478-237-7501
Mailing Address - Fax:478-289-2501
Practice Address - Street 1:50 HWY 56 NORTH
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401
Practice Address - Country:US
Practice Address - Phone:478-237-7501
Practice Address - Fax:478-289-2501
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN054416164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse