Provider Demographics
NPI:1356856561
Name:AMOS- JOHNSON, CASSANDRA (FNP-C)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:AMOS- JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:SHARONETTE
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:111 ROWAN OAK PL
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-7809
Mailing Address - Country:US
Mailing Address - Phone:601-540-8260
Mailing Address - Fax:
Practice Address - Street 1:503 SILVER CROSS DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2388
Practice Address - Country:US
Practice Address - Phone:601-833-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902422363LF0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine