Healthcare Provider Details

I. General information

NPI: 1578493375
Provider Name (Legal Business Name): KANIA MAE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W END BLVD STE 100
ST LOUIS PARK MN
55416-5369
US

IV. Provider business mailing address

2346 THOMAS AVE N
MINNEAPOLIS MN
55411-2356
US

V. Phone/Fax

Practice location:
  • Phone: 763-331-2161
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: