Provider Demographics
NPI:1356330633
Name:JOHNSON, LINDA ANN (MD FNP C)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30920 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-7738
Mailing Address - Country:US
Mailing Address - Phone:248-515-7513
Mailing Address - Fax:
Practice Address - Street 1:30920 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-7738
Practice Address - Country:US
Practice Address - Phone:248-515-7513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704175110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104489651Medicaid
MI104489651Medicaid
ON66420Medicare ID - Type Unspecified