Healthcare Provider Details

I. General information

NPI: 1982011979
Provider Name (Legal Business Name): AMANDA JOHNSON APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA HALVERSON

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-5423
  • Fax:
Mailing address:
  • Phone: 701-234-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR34824
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR34824
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR34824
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: