Provider Demographics
NPI:1225279714
Name:JOHNSON, RANDI YVONNE (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:YVONNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:YVONNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN MSN FNP-BC
Mailing Address - Street 1:PO BOX 824112
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4112
Mailing Address - Country:US
Mailing Address - Phone:215-871-6844
Mailing Address - Fax:215-871-6932
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:STE 315
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6844
Practice Address - Fax:215-874-6932
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010221163W00000X, 163WG0600X, 163WH0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA147427Medicare PIN