Provider Demographics
NPI:1174237705
Name:JOHNSON, DAVID P (FNP-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10229 CARRIAGE CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-9191
Mailing Address - Country:US
Mailing Address - Phone:574-936-1916
Mailing Address - Fax:
Practice Address - Street 1:1904 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7828
Practice Address - Country:US
Practice Address - Phone:574-914-6048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013448A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71013448AOtherAPRN PRECRIPTION AUTHORITY