Provider Demographics
NPI:1720071939
Name:JOHNSON, LINDA R (CNM)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 W DEAN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9406
Mailing Address - Country:US
Mailing Address - Phone:734-847-8100
Mailing Address - Fax:734-847-6824
Practice Address - Street 1:1715 W DEAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9406
Practice Address - Country:US
Practice Address - Phone:734-847-8100
Practice Address - Fax:734-847-6824
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704214498367A00000X
OHNM04013367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104414006Medicaid
OH2343324Medicaid
OH2343324Medicaid