Provider Demographics
NPI:1578714192
Name:JOHNSON, MARNE LEE (RN)
Entity Type:Individual
Prefix:MS
First Name:MARNE
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 87TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55808-1420
Mailing Address - Country:US
Mailing Address - Phone:218-464-0570
Mailing Address - Fax:
Practice Address - Street 1:4815 BURNING TREE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3800
Practice Address - Country:US
Practice Address - Phone:218-733-0707
Practice Address - Fax:218-733-0717
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR-163929-30163W00000X
MNR-168987-0163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse