Healthcare Provider Details

I. General information

NPI: 1639226228
Provider Name (Legal Business Name): LORRIE JOHNSEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9138 LYNISS DR
COMMERCE TOWNSHIP MI
48390-1735
US

IV. Provider business mailing address

9138 LYNISS DR
COMMERCE TOWNSHIP MI
48390-1735
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-9284
  • Fax:
Mailing address:
  • Phone: 248-669-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: