Provider Demographics
NPI:1457798332
Name:JOHNSON, ARETHA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ARETHA
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W GARDEN STREET
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-680-7637
Practice Address - Street 1:2321 N WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-680-7637
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010440363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily