Provider Demographics
NPI:1902213697
Name:JOHNSON, SIMIRA (NP)
Entity Type:Individual
Prefix:
First Name:SIMIRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0871
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:15474 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4893
Practice Address - Country:US
Practice Address - Phone:734-335-6103
Practice Address - Fax:734-404-5317
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704239161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235125717Medicaid