Basic Information
| Provider Information | |||||||||
| NPI: | 1720303043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DELORES | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1267 | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270301267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367893025 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 S SOUTH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367893025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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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 | 363LF0000X | 139733 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 5004674 | 01 | NC | LICENSE | OTHER |