MEDICARE: MRS. MATTIE B. JOHNSON AGPCNP

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	363LP2300X	Primary Care Nurse Practitioner	4704224916	MI

General Provider Information

NPI Number	:	1750808648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MATTIE B. JOHNSON AGPCNP

Provider Business Mailing Address
First Line	:	13599 VIRGIL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-3050
Country	:	US
Telephone Number	:	313-535-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	13599 VIRGIL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-3050
Country	:	US
Telephone Number	:	313-535-6050
Fax Number	:	313-535-6050

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

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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Directions to “ MRS. MATTIE B. JOHNSON AGPCNP” Practice Location

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