Healthcare Provider Details

I. General information

NPI: 1922338086
Provider Name (Legal Business Name): VICKIE M JOHNSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41800 W 11 MILE RD STE 109
NOVI MI
48375-1818
US

IV. Provider business mailing address

PO BOX 22403
BELFAST ME
04915-4476
US

V. Phone/Fax

Practice location:
  • Phone: 847-275-9504
  • Fax:
Mailing address:
  • Phone: 888-402-7256
  • Fax: 888-902-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number13530
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5022905
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13530
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: