Basic Information
| Provider Information | |||||||||
| NPI: | 1386058345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 880 | ||||||||
| Address2: | |||||||||
| City: | ST. IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067453529 | ||||||||
| Practice Location | |||||||||
| Address1: | #5 4TH AVE. E. | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067453529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | AP60763595 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 364SF0001X | NUR-APRN-LIC-100778 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
| ID | Type | State | Issuer | Description | 1386058345 | 05 | WA | MEDICAID |