Provider Demographics
NPI:1043092349
Name:JOHNSON, MICHAELA JULIET (CO)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:JULIET
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 CREEKSHIRE WAY APT 346
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4055
Mailing Address - Country:US
Mailing Address - Phone:301-448-5648
Mailing Address - Fax:
Practice Address - Street 1:1399 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:301-448-5648
Practice Address - Fax:336-768-4869
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCO006801222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist