Healthcare Provider Details

I. General information

NPI: 1083662217
Provider Name (Legal Business Name): CAROL JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E JOLLY RD STE 112
LANSING MI
48910-6818
US

IV. Provider business mailing address

812 E JOLLY RD STE 210
LANSING MI
48910-6818
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8405
  • Fax: 517-346-8291
Mailing address:
  • Phone: 517-346-8410
  • Fax: 517-346-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704074007
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: