Provider Demographics
NPI:1588794713
Name:JOHNSON, MARILOU A (APN)
Entity type:Individual
Prefix:
First Name:MARILOU
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-345-0394
Mailing Address - Fax:309-345-4207
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-345-0394
Practice Address - Fax:309-345-4207
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209001427Medicaid