Healthcare Provider Details

I. General information

NPI: 1225954134
Provider Name (Legal Business Name): RIQUEL JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 KINLOCH CT
COVINGTON GA
30014-8923
US

IV. Provider business mailing address

5 KINLOCH CT
COVINGTON GA
30014-8923
US

V. Phone/Fax

Practice location:
  • Phone: 470-612-1483
  • Fax:
Mailing address:
  • Phone: 470-612-1483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number100281609
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: