Basic Information
Provider Information | |||||||||
NPI: | 1578550992 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM, CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5215 AVONDALE ST | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558041311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2185254945 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 927 TRETTEL LN | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 557201345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791227 | ||||||||
FaxNumber: | 2188782136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2005 | ||||||||
LastUpdateDate: | 05/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R123626-8 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 363LF0000X | R123626-8 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 642215200 | 05 | MN |   | MEDICAID |