Provider Demographics
NPI:1124562186
Name:SEBASTIAN, JOHNY
Entity type:Individual
Prefix:
First Name:JOHNY
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 BURNINGBUSH DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-4525
Mailing Address - Country:US
Mailing Address - Phone:586-604-9609
Mailing Address - Fax:
Practice Address - Street 1:38855 HILLS TECH DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3421
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:248-994-8005
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289322163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse