Provider Demographics
NPI:1063846467
Name:JOHNSON, MIKA LYNN (APRN, CNP)
Entity type:Individual
Prefix:
First Name:MIKA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:MIKA
Other - Middle Name:LYNN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1051 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-8354
Mailing Address - Country:US
Mailing Address - Phone:815-454-2811
Mailing Address - Fax:815-454-2832
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8354
Practice Address - Country:US
Practice Address - Phone:815-454-2811
Practice Address - Fax:815-454-2832
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015838363L00000X
IL277001258363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care