MEDICARE: MICHELLE DAWN JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704212503	MI

General Provider Information

NPI Number	:	1083015424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE DAWN JOHNSON

Provider Business Mailing Address
First Line	:	2003 ORCHARD ST
Second Line	:
City	:	MARQUETTE
State	:	MI
Zip	:	49855-2407
Country	:	US
Telephone Number	:	906-360-1080
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 ORCHARD ST
Second Line	:
City	:	MARQUETTE
State	:	MI
Zip	:	49855
Country	:	US
Telephone Number	:	906-360-1080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	09/04/2014

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