Provider Demographics
NPI:1578833919
Name:JOHNSON, BRIDGET RENEE
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:RENEE
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 1:20090 210TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:49688-8210
Mailing Address - Country:US
Mailing Address - Phone:231-829-5095
Mailing Address - Fax:
Practice Address - Street 1:20090 210TH AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:MI
Practice Address - Zip Code:49688-8210
Practice Address - Country:US
Practice Address - Phone:231-829-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF670251586171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor