Provider Demographics
NPI:1558030544
Name:JOHNSON, DOMINIQUE (RN)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:SHERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6809 TIMBER RIDGE DR S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4776
Mailing Address - Country:US
Mailing Address - Phone:612-513-3778
Mailing Address - Fax:
Practice Address - Street 1:6809 TIMBER RIDGE DR S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4776
Practice Address - Country:US
Practice Address - Phone:612-513-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2469227163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health