MEDICARE: CARLA B 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	163W00000X	Registered Nurse	4704195225	MI

General Provider Information

NPI Number	:	1700397585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA B JOHNSON

Provider Business Mailing Address
First Line	:	10000 CORNING ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2902
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10000 CORNING ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2902
Country	:	US
Telephone Number	:	248-986-4751
Fax Number	:

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

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	10/19/2017

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Directions to “ CARLA B JOHNSON ” Practice Location

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