Healthcare Provider Details

I. General information

NPI: 1891097374
Provider Name (Legal Business Name): ANITA PATRICIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 02/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 EMERSON AVE S APT 1
MINNEAPOLIS MN
55408-2717
US

IV. Provider business mailing address

1622 BOHLAND AVE
SAINT PAUL MN
55116-2121
US

V. Phone/Fax

Practice location:
  • Phone: 612-695-3225
  • Fax:
Mailing address:
  • Phone: 612-695-3225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 0261
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: