Provider Demographics
NPI:1710526629
Name:DELEON, JOHANNA JOYCE (RN 4704309320)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:JOYCE
Last Name:DELEON
Suffix:
Gender:F
Credentials:RN 4704309320
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 CHANDLER PARK DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2081
Mailing Address - Country:US
Mailing Address - Phone:586-883-1351
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-927-4700
Practice Address - Fax:313-923-8390
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309320163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty