Provider Demographics
NPI:1730432071
Name:JOHNSON, WENDI LYNN (APN-FNP)
Entity type:Individual
Prefix:MRS
First Name:WENDI
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN-FNP
Other - Prefix:
Other - First Name:WENDI
Other - Middle Name:LYNN
Other - Last Name:LIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-351-4878
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009855363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification