Provider Demographics
NPI:1356650238
Name:JOHNSON, SANDY JO (BSN)
Entity Type:Individual
Prefix:MRS
First Name:SANDY
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 147TH LANE
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-226-5897
Mailing Address - Fax:
Practice Address - Street 1:20132 ULYSSES STREET. NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-753-8658
Practice Address - Fax:763-753-4314
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR106445-6163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health