Healthcare Provider Details

I. General information

NPI: 1023867785
Provider Name (Legal Business Name): RENEE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MITCHELL BRIDGE RD
ATHENS GA
30606-2043
US

IV. Provider business mailing address

2245 EWELL PARK DR
LAWRENCEVILLE GA
30043-1708
US

V. Phone/Fax

Practice location:
  • Phone: 706-389-6789
  • Fax:
Mailing address:
  • Phone: 404-932-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407505
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number2025040897
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259072
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: