Provider Demographics
NPI:1578550992
Name:JOHNSON, MARY JO (CNM, CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15014 BRIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-5618
Mailing Address - Country:US
Mailing Address - Phone:218-340-7369
Mailing Address - Fax:
Practice Address - Street 1:3625 W 65TH ST STE 100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2147
Practice Address - Country:US
Practice Address - Phone:952-920-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR123626-8367A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN642215200Medicaid
MN642215200Medicaid
MN500027172Medicare ID - Type Unspecified