Provider Demographics
NPI:1508619560
Name:JOHNSON, CORLONDA DESIREE
Entity Type:Individual
Prefix:MS
First Name:CORLONDA
Middle Name:DESIREE
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 1:11224 COURVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2464
Mailing Address - Country:US
Mailing Address - Phone:313-739-5208
Mailing Address - Fax:
Practice Address - Street 1:11224 COURVILLE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2464
Practice Address - Country:US
Practice Address - Phone:313-739-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health