Provider Demographics
NPI:1629020672
Name:JOHNSON, ALICIA ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7854 S STH SHR DR APT 508
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-5374
Mailing Address - Country:US
Mailing Address - Phone:312-498-6834
Mailing Address - Fax:
Practice Address - Street 1:121 FAIRFIELD WAY STE 207
Practice Address - Street 2:STE 207
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1559
Practice Address - Country:US
Practice Address - Phone:630-529-7427
Practice Address - Fax:630-529-9937
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant