Healthcare Provider Details

I. General information

NPI: 1659014116
Provider Name (Legal Business Name): MISS DEMIA NICOLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2284 S BALLENGER HWY STE G
FLINT MI
48503-3446
US

IV. Provider business mailing address

5010 WESTERN RD
FLINT MI
48506-1823
US

V. Phone/Fax

Practice location:
  • Phone: 810-221-7871
  • Fax:
Mailing address:
  • Phone: 810-391-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: