Provider Demographics
NPI:1982581534
Name:JOHNSON, ANITRA (RN)
Entity type:Individual
Prefix:
First Name:ANITRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 ELMORE AVE APT K7
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3592
Mailing Address - Country:US
Mailing Address - Phone:563-210-6871
Mailing Address - Fax:
Practice Address - Street 1:4230 11TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-6746
Practice Address - Country:US
Practice Address - Phone:309-788-4571
Practice Address - Fax:309-788-7132
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041473737163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)