Provider Demographics
NPI:1043601057
Name:JOHNSON, JOHNNIE DOMINICA (FNP)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:DOMINICA
Last Name:JOHNSON
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:JOHNNIE
Other - Middle Name:DOMINICA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:100 W 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2003
Practice Address - Country:US
Practice Address - Phone:708-730-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001345363LA2200X
IL209012407363LF0000X
IL277-001345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL277001345Medicaid
IL277001345Medicaid