Provider Demographics
NPI:1619370764
Name:JOHNSON, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
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 1:15565 NORTHLAND DR W STE 411
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5317
Mailing Address - Country:US
Mailing Address - Phone:248-559-5301
Mailing Address - Fax:248-559-5692
Practice Address - Street 1:15565 NORTHLAND DR W STE 411
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5317
Practice Address - Country:US
Practice Address - Phone:248-559-5301
Practice Address - Fax:248-559-5692
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other