Provider Demographics
NPI:1760889166
Name:JOHNSON, KAREN RUTH (NP-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:RUTH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 W CLARK RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1120
Mailing Address - Country:US
Mailing Address - Phone:734-528-5700
Mailing Address - Fax:734-528-5701
Practice Address - Street 1:3145 W CLARK RD
Practice Address - Street 2:SUITE 401
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1120
Practice Address - Country:US
Practice Address - Phone:734-528-5700
Practice Address - Fax:734-528-5701
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704221733363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN70790087Medicare PIN