Provider Demographics
NPI:1750808648
Name:JOHNSON, MATTIE B (AGPCNP)
Entity type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13599 VIRGIL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-3050
Mailing Address - Country:US
Mailing Address - Phone:313-535-6050
Mailing Address - Fax:
Practice Address - Street 1:13599 VIRGIL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-3050
Practice Address - Country:US
Practice Address - Phone:313-535-6050
Practice Address - Fax:313-535-6050
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224916363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care