Healthcare Provider Details

I. General information

NPI: 1952247405
Provider Name (Legal Business Name): CALEB JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1058 BLAIR AVE
SAINT PAUL MN
55104-2120
US

IV. Provider business mailing address

1058 BLAIR AVE
SAINT PAUL MN
55104-2120
US

V. Phone/Fax

Practice location:
  • Phone: 507-514-0449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14057
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: