MEDICARE: AMANDA-GRACE JOHNSON DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	816524	NV
2	363LF0000X	Family Nurse Practitioner	816524	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	816524	OTHER	NV	STATE LICENSE

General Provider Information

NPI Number	:	1790385136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA-GRACE JOHNSON DNP

Provider Business Mailing Address
First Line	:	6355 S BUFFALO DR FL 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2133
Country	:	US
Telephone Number	:	702-216-3346
Fax Number	:	702-671-6883

Provider Business Practice Location Address
First Line	:	1297 BOULDER CITY PKWY STE A
Second Line	:
City	:	BOULDER CITY
State	:	NV
Zip	:	89005-1854
Country	:	US
Telephone Number	:	702-294-1919
Fax Number	:	702-294-0072

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/18/2022

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