Basic Information
| Provider Information | |||||||||
| NPI: | 1568441491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15500 LUNDY PKWY | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135865011 | ||||||||
| FaxNumber: | 3137927134 | ||||||||
| Practice Location | |||||||||
| Address1: | 7330 N CANTON CENTER RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481871538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344544001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | VJ053315 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | VJ053315 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 444718810 | 05 | MI | MEDICAID |