Provider Demographics
NPI:1417338039
Name:JOHNSON, MICHELLE DAWN
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 S 592 RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-4503
Mailing Address - Country:US
Mailing Address - Phone:918-541-0500
Mailing Address - Fax:
Practice Address - Street 1:1519 E. STEVE OWENS BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354
Practice Address - Country:US
Practice Address - Phone:918-540-1511
Practice Address - Fax:918-289-0551
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator