Provider Demographics
NPI:1043585573
Name:JOHNSON, BRIAN D (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 N GALENA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1568
Mailing Address - Country:US
Mailing Address - Phone:815-285-2273
Mailing Address - Fax:815-285-2276
Practice Address - Street 1:841 N GALENA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1568
Practice Address - Country:US
Practice Address - Phone:815-285-2273
Practice Address - Fax:815-285-2276
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009443207P00000X, 363LP2300X
IAA151173207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine