Provider Demographics
NPI:1376115865
Name:JOHNSON, TUCKER LEE (FNP)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-9500
Mailing Address - Fax:910-662-9501
Practice Address - Street 1:1415 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7338
Practice Address - Country:US
Practice Address - Phone:910-662-9500
Practice Address - Fax:910-662-9501
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261515163W00000X
NC5014723363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse