Provider Demographics
NPI:1851673669
Name:JOHNSON, NADENE (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:NADENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 E GATE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-5915
Mailing Address - Country:US
Mailing Address - Phone:815-243-0341
Mailing Address - Fax:
Practice Address - Street 1:1917 E GATE PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-5915
Practice Address - Country:US
Practice Address - Phone:815-243-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227007520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist