Provider Demographics
NPI:1295014520
Name:JOHNSON, KIMBERLY ANN (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BAKKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4899 MILLER TRUNK HWY STE 208
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1582
Mailing Address - Country:US
Mailing Address - Phone:218-727-3888
Mailing Address - Fax:218-260-4772
Practice Address - Street 1:4899 MILLER TRUNK HWY STE 208
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1582
Practice Address - Country:US
Practice Address - Phone:218-727-3888
Practice Address - Fax:218-260-4772
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295014520Medicaid
WI1295014520Medicaid
WI1295014520Medicaid
MN1295014520Medicaid