Healthcare Provider Details

I. General information

NPI: 1477914158
Provider Name (Legal Business Name): LISA ANNETTE JOHNSON FNP, DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 N KENMORE AVE
CHICAGO IL
60640-5015
US

IV. Provider business mailing address

14313 S PARNELL AVE
RIVERDALE IL
60827-2316
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-9868
  • Fax:
Mailing address:
  • Phone: 773-676-6059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013768
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: