Provider Demographics
NPI:1902492432
Name:JOHNSON, AMANDA MILLAY
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MILLAY
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 1:20 BLUE LACE DR
Mailing Address - Street 2:
Mailing Address - City:WHITELAND
Mailing Address - State:IN
Mailing Address - Zip Code:46184-7022
Mailing Address - Country:US
Mailing Address - Phone:317-586-1481
Mailing Address - Fax:
Practice Address - Street 1:1 CVS DR
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-6146
Practice Address - Country:US
Practice Address - Phone:317-586-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28231306A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse