Provider Demographics
NPI:1235260993
Name:PRAIRIE ST. JOHNS
Entity Type:Organization
Organization Name:PRAIRIE ST. JOHNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNAMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-476-7208
Mailing Address - Street 1:110 W GRANT ST APT 9J
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2311
Mailing Address - Country:US
Mailing Address - Phone:612-940-1546
Mailing Address - Fax:
Practice Address - Street 1:11610 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2009
Practice Address - Country:US
Practice Address - Phone:952-230-9180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14993282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren