Provider Demographics
NPI:1235582958
Name:JOHNSON, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
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 1:300 W WOODYARD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGE FARM
Mailing Address - State:IL
Mailing Address - Zip Code:61870-9467
Mailing Address - Country:US
Mailing Address - Phone:217-497-4612
Mailing Address - Fax:
Practice Address - Street 1:300 W WOODYARD AVE
Practice Address - Street 2:
Practice Address - City:RIDGE FARM
Practice Address - State:IL
Practice Address - Zip Code:61870-9467
Practice Address - Country:US
Practice Address - Phone:217-497-4612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001187780146N00000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic