Provider Demographics
NPI:1881036432
Name:JOHNSON, TAWANTA L (ANP)
Entity Type:Individual
Prefix:
First Name:TAWANTA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3957 ALBERS POINTE DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-1051
Mailing Address - Country:US
Mailing Address - Phone:314-952-0931
Mailing Address - Fax:
Practice Address - Street 1:3957 ALBERS POINTE DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034
Practice Address - Country:US
Practice Address - Phone:314-952-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010465363LA2200X
MO2012039515363LA2200X
MO2015019142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health