Basic Information
| Provider Information | |||||||||
| NPI: | 1871923771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TAWANDA | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 E UNION ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623326150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15055 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 2563835911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R864204 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02602740 | 05 | MS | MEDICAID |