Healthcare Provider Details

I. General information

NPI: 1699756668
Provider Name (Legal Business Name): VICTORIA R NICHOLS-JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST 6TH FLOOR
SPRINGFIELD IL
62702-5317
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-5117
  • Fax: 217-545-7958
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: