=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144808676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J&J MOBILE MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2021
-----------------------------------------------------
Last Update Date | 04/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5918 FARMCREST PT SE
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-589-5623
-----------------------------------------------------
Fax | 470-412-6080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5918 FARMCREST PT SE
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-589-5623
-----------------------------------------------------
Fax | 470-412-6080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | MRS. MICHELLE M JOHNSON
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 404-589-5623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------