Healthcare Provider Details

I. General information

NPI: 1720654056
Provider Name (Legal Business Name): MS. DININA JOHNSON DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 S 4TH ST
MINNEAPOLIS MN
55454-1155
US

IV. Provider business mailing address

1615 S 4TH ST
MINNEAPOLIS MN
55454-1155
US

V. Phone/Fax

Practice location:
  • Phone: 952-688-9499
  • Fax:
Mailing address:
  • Phone: 952-688-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number7374559
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: