Healthcare Provider Details

I. General information

NPI: 1306750468
Provider Name (Legal Business Name): TIFFANY JOHNSON CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E 38TH ST
MINNEAPOLIS MN
55409-1300
US

IV. Provider business mailing address

3449 LYNDALE AVE N
MINNEAPOLIS MN
55412-2555
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-6301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: