Provider Demographics
NPI:1205292059
Name:JOHNSON, BROOKE N (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 NORTHWINDS DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5041
Mailing Address - Country:US
Mailing Address - Phone:309-781-8597
Mailing Address - Fax:
Practice Address - Street 1:2900 FOXFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-377-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-10
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006560363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant