Provider Demographics
NPI:1316610256
Name:JOHNSON, ANDREA MARIE (PMHNP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 RUTH ANN DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5913
Mailing Address - Country:US
Mailing Address - Phone:618-214-1178
Mailing Address - Fax:
Practice Address - Street 1:444 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-436-5665
Practice Address - Fax:618-436-8042
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023676363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health