Healthcare Provider Details

I. General information

NPI: 1447075866
Provider Name (Legal Business Name): CHANCE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

830 BRENTWOOD AVE
SEDALIA MO
65301-8696
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax:
Mailing address:
  • Phone: 660-525-6755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2026023765
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: