Provider Demographics
NPI:1568706893
Name:JOHNSON, LORI LYNN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
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 1:3986 N OCEANA DR
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-8358
Mailing Address - Country:US
Mailing Address - Phone:231-873-2193
Mailing Address - Fax:231-873-4248
Practice Address - Street 1:3986 N OCEANA DR
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-8358
Practice Address - Country:US
Practice Address - Phone:231-873-2193
Practice Address - Fax:231-873-4248
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269946363L00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner