Provider Demographics
NPI:1366849069
Name:JOHNSON, THERESA (DNP, MS,FNP-BC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DNP, MS,FNP-BC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:THERESA JOHNSON, NP
Mailing Address - Street 1:17778 VIOLET DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2098
Mailing Address - Country:US
Mailing Address - Phone:483-182-2092
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:313-334-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285116363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily