Provider Demographics
NPI:1508387937
Name:JOHNSON, HEATHER A
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15526 SHADY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-3017
Mailing Address - Country:US
Mailing Address - Phone:612-269-5183
Mailing Address - Fax:
Practice Address - Street 1:3208 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3447
Practice Address - Country:US
Practice Address - Phone:612-269-5183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
MN2045171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist