Provider Demographics
NPI:1558604801
Name:JOHNSON, ANTWONE SR (LPN)
Entity Type:Individual
Prefix:
First Name:ANTWONE
Middle Name:
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-1311
Mailing Address - Country:US
Mailing Address - Phone:313-829-2557
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2139
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110366164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse