Provider Demographics
NPI:1730072125
Name:JOHNSON, DEONTA L
Entity type:Individual
Prefix:
First Name:DEONTA
Middle Name:L
Last Name:JOHNSON
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 1:15401 GILCHRIST ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1574
Mailing Address - Country:US
Mailing Address - Phone:313-624-5168
Mailing Address - Fax:
Practice Address - Street 1:2220 LAWRENCE ST APT B1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1568
Practice Address - Country:US
Practice Address - Phone:313-551-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider