Individual
MS. NICOLE A JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
Mailing address
PO BOX 3988, CARBONDALE, IL 62902-3988
(618) 457-5200
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085-002903
IL
363AM0700X
Medical Physician Assistant
036-087287
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085-002903
PA LICENSE NUMBER
IL
Enumeration date
02/09/2007
Last updated
11/09/2021
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