Provider Demographics
NPI:1467015511
Name:JOHNSON, IFETAYO B
Entity Type:Individual
Prefix:MS
First Name:IFETAYO
Middle Name:B
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 1:3031 W GRAND BLVD STE 365
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3014
Mailing Address - Country:US
Mailing Address - Phone:313-664-0100
Mailing Address - Fax:313-664-0111
Practice Address - Street 1:3031 W GRAND BLVD STE 365
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3014
Practice Address - Country:US
Practice Address - Phone:313-664-0100
Practice Address - Fax:313-664-0111
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty