Healthcare Provider Details

I. General information

NPI: 1083211981
Provider Name (Legal Business Name): REBECCA ESCAMILLA JOHNSTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2020
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

22101 MOROSS RD
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 586-322-9304
  • Fax:
Mailing address:
  • Phone: 586-322-9304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704286033NSA20011
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: