Provider Demographics
NPI:1164071882
Name:JOHNSTON-PORTER, AMANDA MARIE (CRPA-P)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:JOHNSTON-PORTER
Suffix:
Gender:F
Credentials:CRPA-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1708
Mailing Address - Country:US
Mailing Address - Phone:315-539-1957
Mailing Address - Fax:315-539-4393
Practice Address - Street 1:31 THURBER DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1665
Practice Address - Country:US
Practice Address - Phone:315-539-1985
Practice Address - Fax:315-539-4393
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist