Healthcare Provider Details

I. General information

NPI: 1730572660
Provider Name (Legal Business Name): TIFFANY SHANDREA JOHNSON FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 GRATIOT AVE
DETROIT MI
48207-2372
US

IV. Provider business mailing address

11305 PIERSON ST
DETROIT MI
48228-1247
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone: 248-798-7820
  • Fax: 336-654-0824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704282282
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704282282
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: