Healthcare Provider Details

I. General information

NPI: 1750109898
Provider Name (Legal Business Name): MADELINE MARIE JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 NORTHSIDE DR
VALDOSTA GA
31602-1858
US

IV. Provider business mailing address

220 NORTHSIDE DR
VALDOSTA GA
31602-1858
US

V. Phone/Fax

Practice location:
  • Phone: 229-241-2800
  • Fax:
Mailing address:
  • Phone: 229-241-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN278416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: