Provider Demographics
NPI:1639690191
Name:JOHNSON, TERESA (APRN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST, PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:161-851-9920
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:1006 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1539
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-985-3774
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner