Provider Demographics
NPI:1851060636
Name:JOHNSON, AMANDA NYCOL (CPNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NYCOL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1772 STIEGER LAKE LN STE 220
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-7720
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:952-443-4604
Practice Address - Street 1:1772 STIEGER LAKE LN STE 220
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-7720
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:952-443-4604
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8495363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner