Provider Demographics
NPI:1912763376
Name:JOHNSON, DANIELLE LYNETTE (BA CHW)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LYNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15325 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1328
Mailing Address - Country:US
Mailing Address - Phone:877-544-6722
Mailing Address - Fax:
Practice Address - Street 1:15325 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1328
Practice Address - Country:US
Practice Address - Phone:877-544-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty