Provider Demographics
NPI:1790176402
Name:JOHNSON, TODD RICHARD (APRN)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-4703
Mailing Address - Country:US
Mailing Address - Phone:217-333-7006
Mailing Address - Fax:217-244-6495
Practice Address - Street 1:1109 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-4703
Practice Address - Country:US
Practice Address - Phone:217-333-7006
Practice Address - Fax:217-244-6495
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277003669363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner