Provider Demographics
NPI:1184090920
Name:JOHNSON, MANDI JO (FNP-BC)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26147-7100
Mailing Address - Country:US
Mailing Address - Phone:304-354-9244
Mailing Address - Fax:304-354-5963
Practice Address - Street 1:186 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26147
Practice Address - Country:US
Practice Address - Phone:304-354-9244
Practice Address - Fax:304-354-5963
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV75549363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily