MEDICARE: MARTHA PETERING JOHNSON RN, APN.CNS, IBCLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	2209-005707	IL

General Provider Information

NPI Number	:	1538370994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA PETERING JOHNSON RN, APN.CNS, IBCLC

Provider Business Mailing Address
First Line	:	4138 N HARDING AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1943
Country	:	US
Telephone Number	:	773-267-0816
Fax Number	:	773-267-0816

Provider Business Practice Location Address
First Line	:	4138 N HARDING AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1943
Country	:	US
Telephone Number	:	773-267-0816
Fax Number	:	773-267-0816

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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