Provider Demographics
NPI:1982781555
Name:JOHNSON, MARY TERESA (RN, APN-BC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TERESA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N COUNTY FARM RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3977
Practice Address - Country:US
Practice Address - Phone:630-682-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002769363LF0000X
IL041-173677163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health