Basic Information
| Provider Information | |||||||||
| NPI: | 1871600247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7409 EAGLE CREST BLVD STE G | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477159136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424020 | ||||||||
| FaxNumber: | 8128424019 | ||||||||
| Practice Location | |||||||||
| Address1: | 7409 EAGLE CREST BLVD STE G | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477159136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424020 | ||||||||
| FaxNumber: | 8128424019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 041340671 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 71011040A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | CA2264 | 01 | RR MEDICARE - GROUP # | OTHER | 71011040A | 01 | IN | STATE MEDICAL LICENSE # | OTHER | P00433892 | 01 | RR MEDICARE INDIVIDUAL # | OTHER |