MEDICARE: EVELIA JOHNSEN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	265163	GA

General Provider Information

NPI Number	:	1760017206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELIA JOHNSEN NP

Provider Business Mailing Address
First Line	:	119 CHIMNEY RD
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-5541
Country	:	US
Telephone Number	:	912-295-5560
Fax Number	:	912-259-5562

Provider Business Practice Location Address
First Line	:	119 CHIMNEY RD
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-5541
Country	:	US
Telephone Number	:	912-295-5560
Fax Number	:	912-295-5562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2020
Last Update Date	:	01/06/2025

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