Provider Demographics
NPI:1669639480
Name:JOHNSTON BRUNO, MARY EILEEN (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:EILEEN
Last Name:JOHNSTON BRUNO
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:EILEEN
Other - Last Name:JOHNSTON BRUNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CWOCN
Mailing Address - Street 1:20646 ABBEY WOODS CT. N.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3162
Mailing Address - Country:US
Mailing Address - Phone:866-216-5708
Mailing Address - Fax:866-216-5707
Practice Address - Street 1:20646 ABBEY WOODS CT. N.
Practice Address - Street 2:SUITE 201
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-3162
Practice Address - Country:US
Practice Address - Phone:866-216-5708
Practice Address - Fax:866-216-5707
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003545163WC2100X, 163WW0000X, 163WX1500X
IL209010075363LA2200X
IL209003545364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist