Healthcare Provider Details

I. General information

NPI: 1376408450
Provider Name (Legal Business Name): KRISTINA B JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 LAKESIDE WAY # 2012
NEWNAN GA
30265-3105
US

IV. Provider business mailing address

2012 LAKESIDE WAY # 2012
NEWNAN GA
30265-3105
US

V. Phone/Fax

Practice location:
  • Phone: 225-264-1251
  • Fax:
Mailing address:
  • Phone: 225-264-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: