Healthcare Provider Details

I. General information

NPI: 1962210203
Provider Name (Legal Business Name): BRITTANY CHYANE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BEE CHYANE JOHNSON

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 08/14/2025
Certification Date: 12/19/2024
Deactivation Date: 12/26/2024
Reactivation Date: 08/14/2025

III. Provider practice location address

1047 HOLLYWOOD ST NE
GRAND RAPIDS MI
49505-3835
US

IV. Provider business mailing address

1047 HOLLYWOOD ST NE
GRAND RAPIDS MI
49505-3835
US

V. Phone/Fax

Practice location:
  • Phone: 860-866-8947
  • Fax:
Mailing address:
  • Phone: 860-866-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberMIIA0059709R
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: