Provider Demographics
NPI:1528365467
Name:JOHNSON, DANIELLE (PA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0051
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:1800 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3822
Practice Address - Country:US
Practice Address - Phone:309-346-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant