Healthcare Provider Details

I. General information

NPI: 1265096234
Provider Name (Legal Business Name): HEATHER MARIE JOHNSON PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-8560
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-8560
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number6560
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6560
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: