MEDICARE: MS. KAISA L JOHNSON C.N.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	R149903-4	MN

General Provider Information

NPI Number	:	1821072992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAISA L JOHNSON C.N.M.

Provider Business Mailing Address
First Line	:	6465 WAYZATA BLVD
Second Line	:	STE 315
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-1728
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6490 EXCELSIOR BLVD
Second Line	:	STE E111
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-4705
Country	:	US
Telephone Number	:	952-993-5029
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	11/17/2014

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