Healthcare Provider Details

I. General information

NPI: 1457842213
Provider Name (Legal Business Name): TYLA ALIECE JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYLA ALIECE STEWART

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DE PAUL DR STE 600
BRIDGETON MO
63044-2515
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018004082
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: