MEDICARE: MICHELE KRIEGER-JOHNSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	041-304463	IL

General Provider Information

NPI Number	:	1205219607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE KRIEGER-JOHNSEN

Provider Business Mailing Address
First Line	:	1505 EASTLAND DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7905
Country	:	US
Telephone Number	:	309-663-2100
Fax Number	:	309-663-8322

Provider Business Practice Location Address
First Line	:	1505 EASTLAND DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7905
Country	:	US
Telephone Number	:	309-663-2100
Fax Number	:	309-663-8322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	07/02/2015

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