Provider Demographics
NPI:1073883146
Name:JOHNSON, ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:2907 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-4546
Mailing Address - Country:US
Mailing Address - Phone:314-938-4438
Mailing Address - Fax:314-938-4434
Practice Address - Street 1:1111 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1020
Practice Address - Country:US
Practice Address - Phone:636-887-3020
Practice Address - Fax:636-887-3022
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011040126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily