Provider Demographics
NPI:1407082118
Name:JOHNSON, AMY BROOK (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BROOK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
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 27877
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0877
Mailing Address - Country:US
Mailing Address - Phone:828-694-8350
Mailing Address - Fax:828-694-7654
Practice Address - Street 1:156 CROSS ROAD DR
Practice Address - Street 2:
Practice Address - City:MILLS RIVER
Practice Address - State:NC
Practice Address - Zip Code:28759-5508
Practice Address - Country:US
Practice Address - Phone:828-891-0060
Practice Address - Fax:828-891-1425
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01019064OtherRR MEDICARE
NC2076265Medicare PIN