Provider Demographics
NPI:1265478549
Name:JOHNSON, SANDRA P (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94220 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-7756
Mailing Address - Country:US
Mailing Address - Phone:541-332-3861
Mailing Address - Fax:541-332-0250
Practice Address - Street 1:525 MADRONA ST
Practice Address - Street 2:
Practice Address - City:PORT ORFORD
Practice Address - State:OR
Practice Address - Zip Code:97465-9552
Practice Address - Country:US
Practice Address - Phone:541-332-3861
Practice Address - Fax:541-332-0250
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550082NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276235Medicaid
OR93-0937095OtherCURRY HEALTH DISTRICT TAX ID
OR38-3990OtherCURRY FAMILY MEDICAL RHC
OR276235OtherCURRY FAMILY MEDICAL MEDICAID
OR93-0937095OtherCURRY HEALTH DISTRICT TAX ID
Q53899Medicare UPIN