Healthcare Provider Details

I. General information

NPI: 1861015893
Provider Name (Legal Business Name): NICOLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HEWITT BLVD
RED WING MN
55066-2848
US

IV. Provider business mailing address

701 HEWITT BLVD
RED WING MN
55066-2848
US

V. Phone/Fax

Practice location:
  • Phone: 651-267-5000
  • Fax:
Mailing address:
  • Phone: 507-377-6285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2370725
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9582
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: