Provider Demographics
NPI:1023382264
Name:JOHNSON, AMANDA BRADLEY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BRADLEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 W ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5718
Mailing Address - Country:US
Mailing Address - Phone:202-610-7160
Mailing Address - Fax:202-610-7164
Practice Address - Street 1:11491 US 70 HWY W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2207
Practice Address - Country:US
Practice Address - Phone:919-550-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024905300Medicaid