Provider Demographics
NPI:1053022087
Name:JOHNSON, ZANDRA (LPN)
Entity type:Individual
Prefix:
First Name:ZANDRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1832
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1013
Mailing Address - Country:US
Mailing Address - Phone:470-819-1138
Mailing Address - Fax:
Practice Address - Street 1:29 TIMBERLAND TRACE CT
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-9669
Practice Address - Country:US
Practice Address - Phone:470-819-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078395164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse