Provider Demographics
NPI:1417632415
Name:JOHNSON, KINSEY LYN (NP)
Entity Type:Individual
Prefix:
First Name:KINSEY
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E ROSE CREEK PKWY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6836
Mailing Address - Country:US
Mailing Address - Phone:701-212-2778
Mailing Address - Fax:
Practice Address - Street 1:1800 21ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5759
Practice Address - Country:US
Practice Address - Phone:701-365-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR47295363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner