Provider Demographics
NPI:1477742047
Name:JOHNSON, DAVID E (ANP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 BOX 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:2090 UADALABENE DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-5430
Practice Address - Fax:618-288-6857
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK45367Medicare PIN