Basic Information
| Provider Information | |||||||||
| NPI: | 1184073421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROSS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR STE 2300 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4755 OGLETOWN STANTON RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197181011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027334200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT210838 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C1-0013171 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.