Provider Demographics
NPI:1477914158
Name:JOHNSON, LISA ANNETTE (FNP, DNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14313 S PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2316
Mailing Address - Country:US
Mailing Address - Phone:773-676-6059
Mailing Address - Fax:
Practice Address - Street 1:4755 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5015
Practice Address - Country:US
Practice Address - Phone:773-989-9868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily