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General NPI Number Information
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NPI Number | 1417406752
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Entity Type | Individual
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Provider Name | SHANTAE MONAE JOHNSON AGACNP-BC
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Gender | Female
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Dates
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Enumeration Date | 09/28/2016
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Last Update Date | 07/29/2025
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Provider Practice Location Address
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Address Line | 100 MACK AVE FL 1
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City | DETROIT
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State | MI
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Zip | 48201-2416
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Country | US
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Telephone | 313-818-8207
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Fax |
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Provider Business Mailing Address
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Address Line | 11331 HAZELTON
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City | REDFORD
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State | MI
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Zip | 48239-1429
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Country | US
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Telephone | 313-231-6110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 4704245204
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License Number State | MI
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