Provider Demographics
NPI:1164896379
Name:JOHNSON, BROOKE (DNP, AGNP-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DNP, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 WOODSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5277
Mailing Address - Country:US
Mailing Address - Phone:605-280-8892
Mailing Address - Fax:
Practice Address - Street 1:12700 WHITEWATER DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9438
Practice Address - Country:US
Practice Address - Phone:612-398-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0992021363LA2200X
MN6468363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health