Healthcare Provider Details

I. General information

NPI: 1861772691
Provider Name (Legal Business Name): MICHELLE TAUNETTE JOHNSON-RUIZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 SOLOFF RD
MASSAPEQUA NY
11758-3739
US

IV. Provider business mailing address

28 SOLOFF RD
MASSAPEQUA NY
11758-3739
US

V. Phone/Fax

Practice location:
  • Phone: 516-809-6673
  • Fax: 516-750-9070
Mailing address:
  • Phone: 516-809-6673
  • Fax: 516-750-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number507242-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number507242-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: