Healthcare Provider Details

I. General information

NPI: 1215008578
Provider Name (Legal Business Name): KIM JOHNSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 STINSON AVE
CHISAGO CITY MN
55013-9542
US

IV. Provider business mailing address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

V. Phone/Fax

Practice location:
  • Phone: 651-257-8458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4201
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: