Healthcare Provider Details

I. General information

NPI: 1609780063
Provider Name (Legal Business Name): TAGJADA JOHNSON NURSE AID
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAGJADA PAYNE

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19994 COVENTRY ST
DETROIT MI
48203-1130
US

IV. Provider business mailing address

19994 COVENTRY ST
DETROIT MI
48203-1130
US

V. Phone/Fax

Practice location:
  • Phone: 586-690-1557
  • Fax:
Mailing address:
  • Phone: 586-690-1557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License NumberMI000021212
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: