Healthcare Provider Details

I. General information

NPI: 1811635014
Provider Name (Legal Business Name): NICOLE JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W. 4TH ST
MAHNOMEN MN
56557
US

IV. Provider business mailing address

47639 192ND ST
BRANDT SD
57218-5731
US

V. Phone/Fax

Practice location:
  • Phone: 218-935-2514
  • Fax:
Mailing address:
  • Phone: 218-280-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022003041
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: