Healthcare Provider Details

I. General information

NPI: 1043019250
Provider Name (Legal Business Name): RADIANT JOURNEY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13691 BALSAM LN N STE C
DAYTON MN
55327-6901
US

IV. Provider business mailing address

13691 BALSAM LN N STE C
DAYTON MN
55327-6901
US

V. Phone/Fax

Practice location:
  • Phone: 763-299-4135
  • Fax:
Mailing address:
  • Phone: 763-299-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELANIE JAPPAH
Title or Position: CEO
Credential: NURSE PRACTITIONER
Phone: 763-229-4135