Provider Demographics
NPI:1508576109
Name:JOHNSON, PAMELA WILLETTE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:WILLETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 HILLCREST CIR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-5623
Mailing Address - Country:US
Mailing Address - Phone:336-925-3396
Mailing Address - Fax:
Practice Address - Street 1:411 HILLCREST CIR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5623
Practice Address - Country:US
Practice Address - Phone:336-925-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCJOHN-IQ01P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner