Healthcare Provider Details

I. General information

NPI: 1912418567
Provider Name (Legal Business Name): ANGELA SANDRA REID APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELA SANDRA JOHNSON

II. Dates (important events)

Enumeration Date: 10/21/2017
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2706 225TH LN NW
BETHEL MN
55005-9317
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-7032
  • Fax:
Mailing address:
  • Phone: 763-360-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberR153636-3
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number5551
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: