Provider Demographics
NPI:1760066187
Name:JOHNSON, PHYLLIS MICHELLE
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MICHELLE
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 1:5601 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-1403
Mailing Address - Country:US
Mailing Address - Phone:305-345-4008
Mailing Address - Fax:305-938-5063
Practice Address - Street 1:5601 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1403
Practice Address - Country:US
Practice Address - Phone:305-345-4008
Practice Address - Fax:305-938-5063
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty