Healthcare Provider Details

I. General information

NPI: 1467926030
Provider Name (Legal Business Name): DAKOTA LANE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 S OLA RD
MCDONOUGH GA
30252-7180
US

IV. Provider business mailing address

779 S OLA RD
MCDONOUGH GA
30252-7180
US

V. Phone/Fax

Practice location:
  • Phone: 678-815-6135
  • Fax:
Mailing address:
  • Phone: 678-815-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: