Healthcare Provider Details

I. General information

NPI: 1164898631
Provider Name (Legal Business Name): MARKIZH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S WELLS ST 303
CHICAGO IL
60609-1867
US

IV. Provider business mailing address

3601 S WELLS ST 303
CHICAGO IL
60609-1867
US

V. Phone/Fax

Practice location:
  • Phone: 773-544-0504
  • Fax:
Mailing address:
  • Phone: 773-544-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209008754
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041340029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: