Healthcare Provider Details

I. General information

NPI: 1407216765
Provider Name (Legal Business Name): LA SHAWNDA MARIE JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1094 ACCESS RD STE B
COVINGTON GA
30014-2048
US

IV. Provider business mailing address

1094 ACCESS RD STE B
COVINGTON GA
30014-2048
US

V. Phone/Fax

Practice location:
  • Phone: 404-330-4263
  • Fax:
Mailing address:
  • Phone: 404-330-4263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT014225
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: