Healthcare Provider Details

I. General information

NPI: 1003287533
Provider Name (Legal Business Name): KACIE PARRISH JOHNSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 N ASHLEY ST STE C
VALDOSTA GA
31602-5911
US

IV. Provider business mailing address

3200 N ASHLEY ST STE C
VALDOSTA GA
31602-5911
US

V. Phone/Fax

Practice location:
  • Phone: 229-671-9100
  • Fax: 229-671-9101
Mailing address:
  • Phone: 229-671-9100
  • Fax: 229-671-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN197323
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN197323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: