Provider Demographics
NPI:1952961567
Name:JOHNSON, KEVIN MICHAEL (FNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47307 LARSON RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC MINE
Mailing Address - State:MI
Mailing Address - Zip Code:49905-9203
Mailing Address - Country:US
Mailing Address - Phone:906-281-2186
Mailing Address - Fax:
Practice Address - Street 1:18341 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8024
Practice Address - Country:US
Practice Address - Phone:906-524-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF06190459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily