Healthcare Provider Details

I. General information

NPI: 1043585573
Provider Name (Legal Business Name): BRIAN D JOHNSON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 10/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 N GALENA AVE SUITE 200
DIXON IL
61021-1568
US

IV. Provider business mailing address

841 N GALENA AVE SUITE 200
DIXON IL
61021-1568
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-2273
  • Fax: 815-285-2276
Mailing address:
  • Phone: 815-285-2273
  • Fax: 815-285-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number209009443
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA151173
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209009443
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: