Healthcare Provider Details

I. General information

NPI: 1952961567
Provider Name (Legal Business Name): KEVIN MICHAEL JOHNSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N5241 US HIGHWAY 45
WATERSMEET MI
49969-0009
US

IV. Provider business mailing address

47307 LARSON RD
ATLANTIC MINE MI
49905-9203
US

V. Phone/Fax

Practice location:
  • Phone: 906-358-4588
  • Fax: 906-358-4118
Mailing address:
  • Phone: 906-281-2186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06190459
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: