Healthcare Provider Details

I. General information

NPI: 1508387937
Provider Name (Legal Business Name): HEATHER A JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 SMITH AVE N STE 203
SAINT PAUL MN
55102-2388
US

IV. Provider business mailing address

15526 SHADY ACRES DR
WADENA MN
56482-3017
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-7733
  • Fax:
Mailing address:
  • Phone: 612-269-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2045
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: