=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043019250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANT JOURNEY HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13691 BALSAM LN N STE C
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-299-4135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13691 BALSAM LN N STE C
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-299-4135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MELANIE JAPPAH
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 763-229-4135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------