Provider Demographics
NPI:1790736007
Name:JOHNSON, KATHLEEN D (APN)
Entity Type:Individual
Prefix:MR
First Name:KATHLEEN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 FRANCISCAN DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1778
Mailing Address - Country:US
Mailing Address - Phone:217-324-6127
Mailing Address - Fax:217-324-5959
Practice Address - Street 1:1285 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1778
Practice Address - Country:US
Practice Address - Phone:217-324-6127
Practice Address - Fax:217-324-5959
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MJ0722264OtherDEA
P02163Medicare UPIN