Provider Demographics
NPI:1881605806
Name:JOHNSON, BEVERLY K
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:K
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:PO BOX 2070
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31515-2070
Mailing Address - Country:US
Mailing Address - Phone:912-367-0653
Mailing Address - Fax:912-367-0656
Practice Address - Street 1:510 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0153
Practice Address - Country:US
Practice Address - Phone:912-367-0653
Practice Address - Fax:912-367-0656
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN106778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000906881CMedicaid
GAP00050414Medicare UPIN
GA000906881CMedicaid