Healthcare Provider Details

I. General information

NPI: 1578550992
Provider Name (Legal Business Name): MARY JO JOHNSON CNM, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 W 65TH ST STE 100
EDINA MN
55435-2147
US

IV. Provider business mailing address

15014 BRIDGEWATER DR
SAVAGE MN
55378-5618
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-7001
  • Fax:
Mailing address:
  • Phone: 218-340-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR123626-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR123626-8
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: