Healthcare Provider Details

I. General information

NPI: 1427178250
Provider Name (Legal Business Name): TATYANNA JOHNSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5789 S MAIN ST
CLARKSTON MI
48346-2959
US

IV. Provider business mailing address

5789 S MAIN ST
CLARKSTON MI
48346-2959
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-0030
  • Fax: 248-625-4403
Mailing address:
  • Phone: 248-625-0030
  • Fax: 248-625-4403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704182339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: