=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023518537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN DELROY JOHNSON FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3088 WASHINGTON RD
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-4566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-444-3135
-----------------------------------------------------
Fax | 404-777-9336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740015
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-0015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-733-9730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN258005
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------