Healthcare Provider Details

I. General information

NPI: 1780548628
Provider Name (Legal Business Name): STEPHANIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WESTMINSTER DR
CANTON GA
30114-8796
US

IV. Provider business mailing address

318 WESTMINSTER DR
CANTON GA
30114-8796
US

V. Phone/Fax

Practice location:
  • Phone: 619-794-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: