Provider Demographics
NPI:1114977527
Name:JOHNSON, ROSALIND C (CRNA)
Entity type:Individual
Prefix:
First Name:ROSALIND
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6779 COMBRAY
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1395
Mailing Address - Country:US
Mailing Address - Phone:248-324-1601
Mailing Address - Fax:
Practice Address - Street 1:22401 FOSTER WINTER DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3724
Practice Address - Country:US
Practice Address - Phone:248-423-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704107228367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN97820010Medicare ID - Type Unspecified