Healthcare Provider Details

I. General information

NPI: 1538370994
Provider Name (Legal Business Name): MARTHA PETERING JOHNSON RN, APN.CNS, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4138 N HARDING AVE
CHICAGO IL
60618-1943
US

IV. Provider business mailing address

4138 N HARDING AVE
CHICAGO IL
60618-1943
US

V. Phone/Fax

Practice location:
  • Phone: 773-267-0816
  • Fax: 773-267-0816
Mailing address:
  • Phone: 773-267-0816
  • Fax: 773-267-0816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2209-005707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: