Provider Demographics
NPI:1386727519
Name:JOHNSON, MOLLY T (FNP-BC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1031
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-351-4878
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:STE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-453-3777
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000639363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL214881Medicare Oscar/Certification
IL522000010Medicare PIN