Healthcare Provider Details

I. General information

NPI: 1881036432
Provider Name (Legal Business Name): TAWANTA L JOHNSON ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 WALL ST STE 302
SAINT CHARLES MO
63303-3541
US

IV. Provider business mailing address

3957 ALBERS POINTE DR
FLORISSANT MO
63034-1051
US

V. Phone/Fax

Practice location:
  • Phone: 314-952-0931
  • Fax:
Mailing address:
  • Phone: 314-952-0931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2012039515
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.010465
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015019142
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: