Healthcare Provider Details

I. General information

NPI: 1427377316
Provider Name (Legal Business Name): MARTHA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-823-3960
Mailing address:
  • Phone: 706-733-0188
  • Fax: 706-823-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN052135
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: