Provider Demographics
NPI:1356781041
Name:JOHNSON, REGINA RENEE (NP)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:REGINA
Other - Middle Name:RENEE
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4301 ORCHARD LAKE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1684
Mailing Address - Country:US
Mailing Address - Phone:313-492-5807
Mailing Address - Fax:
Practice Address - Street 1:4301 ORCHARD LAKE RD STE 180
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-1684
Practice Address - Country:US
Practice Address - Phone:313-492-5807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704236041363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner