Provider Demographics
NPI:1275767378
Name:JOHNSON, JUDY JOANN (OPTICAN)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:JOANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OPTICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7362 UNIVERSITY AVE NE
Mailing Address - Street 2:206
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3142
Mailing Address - Country:US
Mailing Address - Phone:763-571-5450
Mailing Address - Fax:763-571-1880
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:206
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:763-571-5450
Practice Address - Fax:763-571-1880
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156FX1800X156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician