Healthcare Provider Details

I. General information

NPI: 1700710621
Provider Name (Legal Business Name): KATHERINE RENEE JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 51ST ST S STE A
FARGO ND
58104-7897
US

IV. Provider business mailing address

3252 51ST ST S STE A
FARGO ND
58104-7897
US

V. Phone/Fax

Practice location:
  • Phone: 701-261-6351
  • Fax: 701-261-6351
Mailing address:
  • Phone: 701-261-6351
  • Fax: 701-261-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18188
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: