Provider Demographics
NPI:1720303043
Name:JOHNSON, DELORES EDWARDS (FNP)
Entity type:Individual
Prefix:
First Name:DELORES
Middle Name:EDWARDS
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 1:910 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-4458
Mailing Address - Country:US
Mailing Address - Phone:336-786-5108
Mailing Address - Fax:336-783-6842
Practice Address - Street 1:910 WORTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4458
Practice Address - Country:US
Practice Address - Phone:336-786-5108
Practice Address - Fax:336-783-6842
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004674OtherLICENSE
NC5004674OtherLICENSE