Basic Information
| Provider Information | |||||||||
| NPI: | 1790062545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LUDMILA | ||||||||
| MiddleName: | STANISLAVIVNA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GONCHARENKO | ||||||||
| OtherFirstName: | LYUDMYLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 295 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126259900 | ||||||||
| FaxNumber: | 6126257950 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 DELAWARE ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126266688 | ||||||||
| FaxNumber: | 6126263217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R 172283-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.