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General NPI Number Information
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NPI Number | 1619180106
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE ASSISTANTS, INC.
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 10/11/2011
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Provider Practice Location Address
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Address Line | 21200 S LAGRANGE RD SUITE 134
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City | FRANKFORT
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State | IL
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Zip | 60423-2003
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Country | US
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Telephone | 708-256-0816
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Fax | 815-534-5576
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Provider Business Mailing Address
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Address Line | 21200 S LAGRANGE RD SUITE 134
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City | FRANKFORT
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State | IL
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Zip | 60423-2003
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Country | US
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Telephone | 708-256-0816
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Fax | 815-534-5576
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | BRIAN JOHNSON
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Credential | FNP-C, MSN
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Telephone | 708-256-0816
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209009090
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License Number State | IL
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