Provider Demographics
NPI:1417590027
Name:JOHNSON, NEAL (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-570-2760
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1700
Practice Address - Country:US
Practice Address - Phone:847-570-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-26
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020300367500000X
IL041.394585163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse