Healthcare Provider Details

I. General information

NPI: 1962227892
Provider Name (Legal Business Name): CHARLENE JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2024
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-2611
  • Fax:
Mailing address:
  • Phone: 701-237-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2459535
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR41835
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: