Provider Demographics
NPI:1982011979
Name:JOHNSON, AMANDA (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HALVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-5423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34824163W00000X, 363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN722451Medicare PIN
NDN722450Medicare PIN