Provider Demographics
NPI:1447687512
Name:JOHNSON, ANGELETTA ANSLEY (ARNP)
Entity type:Individual
Prefix:MRS
First Name:ANGELETTA
Middle Name:ANSLEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:ANGELETTA
Other - Middle Name:MACHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1625 HOSPITAL SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8111
Mailing Address - Country:US
Mailing Address - Phone:470-732-6950
Mailing Address - Fax:
Practice Address - Street 1:1625 HOSPITAL SOUTH DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8111
Practice Address - Country:US
Practice Address - Phone:470-732-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN116219363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid