Provider Demographics
NPI:1649819129
Name:JOHNSON, WANDA BRESHAE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:BRESHAE
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 1:919 LAWYERS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-653-9242
Practice Address - Street 1:506 MANCHESTER EXPY STE A13
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6483
Practice Address - Country:US
Practice Address - Phone:706-653-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty