Provider Demographics
NPI:1164898631
Name:JOHNSON, MARKIZH
Entity Type:Individual
Prefix:
First Name:MARKIZH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S WELLS ST
Mailing Address - Street 2:303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1867
Mailing Address - Country:US
Mailing Address - Phone:773-544-0504
Mailing Address - Fax:
Practice Address - Street 1:3601 S WELLS ST
Practice Address - Street 2:303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1867
Practice Address - Country:US
Practice Address - Phone:773-544-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041340029163WG0000X
IL209008754364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice