MEDICARE: MRS. AMANDA LORGE JOHNSON FNP-C

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	363LF0000X	Family Nurse Practitioner	0024175961	VA
2	363LF0000X	Family Nurse Practitioner	RN1045832	DC

General Provider Information

NPI Number	:	1205350931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA LORGE JOHNSON FNP-C

Provider Business Mailing Address
First Line	:	4565 DAISY REID AVE
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-5670
Country	:	US
Telephone Number	:	571-297-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	4565 DAISY REID AVE
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-5670
Country	:	US
Telephone Number	:	571-297-1414
Fax Number	:

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

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	12/02/2019

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