Provider Demographics
NPI:1326517731
Name:JOHNSON, ANTONISE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ANTONISE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
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 929
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-0929
Mailing Address - Country:US
Mailing Address - Phone:405-896-8058
Mailing Address - Fax:855-223-1999
Practice Address - Street 1:1334 N LANSING AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-5907
Practice Address - Country:US
Practice Address - Phone:918-587-2171
Practice Address - Fax:918-978-9077
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88183363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty