Provider Demographics
NPI:1790410108
Name:JOHNSON, AUDRE S
Entity Type:Individual
Prefix:
First Name:AUDRE
Middle Name:S
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 1:9723 GARDNER ST LOT 180
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-9489
Mailing Address - Country:US
Mailing Address - Phone:734-330-1868
Mailing Address - Fax:
Practice Address - Street 1:9723 GARDNER ST LOT 180
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-9489
Practice Address - Country:US
Practice Address - Phone:734-330-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health