Healthcare Provider Details

I. General information

NPI: 1689208928
Provider Name (Legal Business Name): MARY CHRISTINE JOHANSEN APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-8070
  • Fax: 815-759-4931
Mailing address:
  • Phone: 815-759-8070
  • Fax: 815-759-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020914
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209020614
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.020914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: