Provider Demographics
NPI:1639457526
Name:JOHNSON, TRICIA SUE (APN)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:SUE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6194
Mailing Address - Country:US
Mailing Address - Phone:309-762-3621
Mailing Address - Fax:309-762-3690
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6194
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner