Provider Demographics
NPI:1124199690
Name:JOHNSON, DANIEL L (FNP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:441 W ELM ST STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3573
Practice Address - Country:US
Practice Address - Phone:417-532-2805
Practice Address - Fax:417-532-2848
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424962306Medicaid
MO424962306Medicaid
MOP04946Medicare UPIN