Healthcare Provider Details

I. General information

NPI: 1871923771
Provider Name (Legal Business Name): TAWANDA JOHNSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15055 COLLECTION CENTER DR
CHICAGO IL
60693-0150
US

IV. Provider business mailing address

1514 E UNION ST
GREENVILLE MS
38703-3248
US

V. Phone/Fax

Practice location:
  • Phone: 256-383-3325
  • Fax: 256-383-5911
Mailing address:
  • Phone: 662-332-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR864204
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: