Healthcare Provider Details

I. General information

NPI: 1699225607
Provider Name (Legal Business Name): SHENA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G3230 BEECHER RD
FLINT MI
48532-3604
US

IV. Provider business mailing address

G3230 BEECHER RD
FLINT MI
48532-3604
US

V. Phone/Fax

Practice location:
  • Phone: 810-342-5620
  • Fax:
Mailing address:
  • Phone: 810-342-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6301016714
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: