Provider Demographics
NPI:1134475759
Name:JOHNSON, ANGELA D (APRN-FPA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN-FPA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:D
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-FPA
Mailing Address - Street 1:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2902 MCFARLAND RD STE 300
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6801
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000127363LA2200X, 363LF0000X, 363L00000X
IL209009641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL433440055Medicare PIN