Individual
NICOLE LEE JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
11531 SUNDERLAND RD, MARION, IL 62959-8274
(618) 201-9907
Mailing address
4713 ELKVILLE RD, VERGENNES, IL 62994-1805
(618) 201-9907
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
043120707
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
164W00000X
TAXONOMY CODE
IL
01
—
J52563291734
DRIVERS LICENSE
IL
Enumeration date
01/25/2019
Last updated
01/25/2019
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