Provider Demographics
NPI:1275625485
Name:JOHNSON, MICHELE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:REHM
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:409 DUNLAP ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4201
Mailing Address - Country:US
Mailing Address - Phone:651-290-9200
Mailing Address - Fax:651-290-9210
Practice Address - Street 1:916 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-5425
Practice Address - Country:US
Practice Address - Phone:651-290-9232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0995940363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN217214300Medicaid
MN217214300Medicaid
MN500002476Medicare Oscar/Certification