MEDICARE: TAWANDA JOHNSON FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R864204	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871923771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAWANDA JOHNSON FNP-BC

Provider Business Mailing Address
First Line	:	1514 E UNION ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3248
Country	:	US
Telephone Number	:	662-332-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	15055 COLLECTION CENTER DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60693-0150
Country	:	US
Telephone Number	:	256-383-3325
Fax Number	:	256-383-5911

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	09/09/2014

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