Provider Demographics
NPI:1043245723
Name:JOHNSON, MARY LOU (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:HEDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1200
Mailing Address - Country:US
Mailing Address - Phone:218-834-7205
Mailing Address - Fax:218-834-7250
Practice Address - Street 1:1010 4TH ST
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1200
Practice Address - Country:US
Practice Address - Phone:218-834-7205
Practice Address - Fax:218-834-7250
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR068214-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse