Provider Demographics
NPI:1508374174
Name:JOHNSON, AMANDA L (CPNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BRENRAY DR
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-5148
Mailing Address - Country:US
Mailing Address - Phone:423-817-5085
Mailing Address - Fax:
Practice Address - Street 1:108 BRENRAY DR
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-5148
Practice Address - Country:US
Practice Address - Phone:423-817-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23469363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics