Healthcare Provider Details

I. General information

NPI: 1639457526
Provider Name (Legal Business Name): TRICIA SUE JOHNSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRICIA SUE LARSON

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

IV. Provider business mailing address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax: 309-762-3690
Mailing address:
  • Phone: 309-762-3621
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.008926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: