Provider Demographics
NPI:1578986873
Name:JOHNSON, ANDREW III (RN)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24240 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3117
Mailing Address - Country:US
Mailing Address - Phone:313-623-3069
Mailing Address - Fax:
Practice Address - Street 1:2900 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2407
Practice Address - Country:US
Practice Address - Phone:313-308-1408
Practice Address - Fax:313-824-5590
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704193600163WC0400X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WC0400XNursing Service ProvidersRegistered NurseCase Management