Provider Demographics
NPI:1568430346
Name:JOHNSON, ICEPHINE BALLARD (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:ICEPHINE
Middle Name:BALLARD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4442
Mailing Address - Country:US
Mailing Address - Phone:320-308-4861
Mailing Address - Fax:320-308-3192
Practice Address - Street 1:720 4TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4442
Practice Address - Country:US
Practice Address - Phone:320-308-4861
Practice Address - Fax:320-308-3192
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 107237-0363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41687554OtherEIN