Provider Demographics
NPI:1861992851
Name:JOHNSON, HEIDI (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2724
Mailing Address - Country:US
Mailing Address - Phone:360-865-1459
Mailing Address - Fax:
Practice Address - Street 1:7717 N ORANGE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9323
Practice Address - Country:US
Practice Address - Phone:309-589-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041414240163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041414240OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION