Healthcare Provider Details

I. General information

NPI: 1417358482
Provider Name (Legal Business Name): BRANDON LEE JOHNSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 CAREW ST STE 120
FORT WAYNE IN
46805-4764
US

IV. Provider business mailing address

341 PONCE DE LEON AVE NE
ATLANTA GA
30308-2012
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6200
  • Fax: 260-425-6205
Mailing address:
  • Phone: 260-615-7118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71018116A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: