Provider Demographics
NPI:1245593110
Name:JOHNSON, TIFFANY RECHANDRA (RN, WHNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:RECHANDRA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:248-353-3078
Mailing Address - Fax:
Practice Address - Street 1:3577 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-16
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248817363LW0102X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health