Provider Demographics
NPI:1194072611
Name:JOHNSON, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
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 1:103 S LANE ST
Mailing Address - Street 2:
Mailing Address - City:BLISSFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49228-1207
Mailing Address - Country:US
Mailing Address - Phone:517-682-0935
Mailing Address - Fax:
Practice Address - Street 1:103 S LANE ST
Practice Address - Street 2:
Practice Address - City:BLISSFIELD
Practice Address - State:MI
Practice Address - Zip Code:49228-1207
Practice Address - Country:US
Practice Address - Phone:517-682-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies