Healthcare Provider Details

I. General information

NPI: 1750122784
Provider Name (Legal Business Name): ASHLEIGH A JOHNSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

IV. Provider business mailing address

13824 CLARE DOWNS WAY
ROSEMOUNT MN
55068-4598
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2020
  • Fax:
Mailing address:
  • Phone: 651-271-0842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3933
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: