Provider Demographics
NPI:1053543348
Name:KING, JOHNNY III (RN, BSN, MPH, BC-APH)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:KING
Suffix:III
Gender:M
Credentials:RN, BSN, MPH, BC-APH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVENUE
Mailing Address - Street 2:STE 1D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-5071
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVENUE
Practice Address - Street 2:STE 1D03
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN087034163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health