Provider Demographics
NPI:1952679987
Name:JOHNSON, AMANDA NICOLE (RPH)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HUNTSVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3442
Mailing Address - Country:US
Mailing Address - Phone:931-433-5569
Mailing Address - Fax:
Practice Address - Street 1:1000 HUNTSVILLE HWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3442
Practice Address - Country:US
Practice Address - Phone:931-433-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25622183500000X
AL15113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4438099OtherNABP