=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689148751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY KRYSTINA JOHNSON-SPANN MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2019
-----------------------------------------------------
Last Update Date | 06/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4591 SAGEBRUSH CT
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-994-5022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4591 SAGEBRUSH CT
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-994-5022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP008355
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------