Basic Information
| Provider Information | |||||||||
| NPI: | 1770110777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON MACK | ||||||||
| FirstName: | STEFFANI | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherLastName: | JOHNSTON | ||||||||
| OtherFirstName: | STEFFANI | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1232 3RD ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013302323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344023 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.