Basic Information
| Provider Information | |||||||||
| NPI: | 1083969513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICKYLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2301 E 93RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606173913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737319898 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2012 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036140087 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.