Healthcare Provider Details

I. General information

NPI: 1750202040
Provider Name (Legal Business Name): THOMAS JOHNSON MCKINNON III PHMNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

IV. Provider business mailing address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

V. Phone/Fax

Practice location:
  • Phone: 404-748-4434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP300384
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: