Healthcare Provider Details

I. General information

NPI: 1801014329
Provider Name (Legal Business Name): MALINDA JOHNSON PA-C, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 01/29/2021
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 NEWNAN CROSSING BYP STE 200
NEWNAN GA
30265-2434
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006226
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008486
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: