Healthcare Provider Details

I. General information

NPI: 1851464754
Provider Name (Legal Business Name): DEBORAH RUTH JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20548 FENKELL ST
DETROIT MI
48223-1613
US

IV. Provider business mailing address

7642 PARK MEADOW LN
WEST BLOOMFIELD MI
48324-4103
US

V. Phone/Fax

Practice location:
  • Phone: 313-255-3333
  • Fax:
Mailing address:
  • Phone: 248-210-3024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704222716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: