Healthcare Provider Details

I. General information

NPI: 1740990803
Provider Name (Legal Business Name): SUSAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 APPLE DR
MATTOON IL
61938-9263
US

IV. Provider business mailing address

24 APPLE DR
MATTOON IL
61938-9263
US

V. Phone/Fax

Practice location:
  • Phone: 217-273-1260
  • Fax:
Mailing address:
  • Phone: 217-273-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: