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General NPI Number Information
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NPI Number | 1154903920
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Entity Type | Individual
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Provider Name | DERICK JOHNSON APRN
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Gender | Male
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Dates
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Enumeration Date | 04/22/2021
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Last Update Date | 09/23/2025
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Provider Practice Location Address
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Address Line | 8543 S STONY ISLAND AVE STE 3
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City | CHICAGO
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State | IL
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Zip | 60617-2249
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Country | US
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Telephone | 312-380-9808
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Fax |
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Provider Business Mailing Address
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Address Line | 11713 S MAPLEWOOD AVE
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City | CHICAGO
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State | IL
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Zip | 60655-1524
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Country | US
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Telephone | 312-380-9808
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209.022844
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License Number State | IL
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