Healthcare Provider Details

I. General information

NPI: 1215595640
Provider Name (Legal Business Name): SAMANTHA ANN JOHNSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RENAISSANCE CTR
DETROIT MI
48243-1502
US

IV. Provider business mailing address

8906 SPANISH RIDGE AVE STE 202
LAS VEGAS NV
89148-1319
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 702-330-3102
  • Fax: 702-912-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberRN71057
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number386709
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: