Provider Demographics
NPI:1083030605
Name:JOHNSON, DOLORES JOYCE
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:JOYCE
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 1:8143 HONEY LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4105
Mailing Address - Country:US
Mailing Address - Phone:734-329-3070
Mailing Address - Fax:
Practice Address - Street 1:8143 HONEY LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4105
Practice Address - Country:US
Practice Address - Phone:734-329-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111370164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse