Healthcare Provider Details

I. General information

NPI: 1639034937
Provider Name (Legal Business Name): KATELYN JOHNSTON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HEAVENLY HAVEN DR
OWOSSO MI
48867-9162
US

IV. Provider business mailing address

2100 HEAVENLY HAVEN DR
OWOSSO MI
48867-9162
US

V. Phone/Fax

Practice location:
  • Phone: 989-627-7242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: