Provider Demographics
NPI:1740201458
Name:JOHNSON, SANDRIVETTE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:SANDRIVETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 SIX FORKS RD STE 211
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-8228
Mailing Address - Country:US
Mailing Address - Phone:984-242-0510
Mailing Address - Fax:984-242-0520
Practice Address - Street 1:5904 SIX FORKS RD STE 211
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8228
Practice Address - Country:US
Practice Address - Phone:984-242-0510
Practice Address - Fax:984-242-0520
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201614363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCY997D895OtherMEDICARE
P02076810OtherRAILROAD MEDICARE
NCP89108Medicare UPIN