Healthcare Provider Details

I. General information

NPI: 1760017206
Provider Name (Legal Business Name): EVELIA JOHNSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BLUE MOON XING STE 102
POOLER GA
31322-9698
US

IV. Provider business mailing address

200 BLUE MOON XING STE 102
POOLER GA
31322-9698
US

V. Phone/Fax

Practice location:
  • Phone: 912-925-6911
  • Fax: 912-330-4060
Mailing address:
  • Phone: 912-925-6911
  • Fax: 912-330-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number265163
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: