Provider Demographics
NPI:1275259202
Name:JOHNSON, EMMA JEAN (BSN, RN)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 FAIRMOUNT ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1506
Mailing Address - Country:US
Mailing Address - Phone:636-459-9066
Mailing Address - Fax:
Practice Address - Street 1:1131 IONIA AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1020
Practice Address - Country:US
Practice Address - Phone:616-323-1122
Practice Address - Fax:616-259-7909
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704365154163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse