Provider Demographics
NPI:1629039821
Name:JOHNSTON, MARY (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 HAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6411
Mailing Address - Country:US
Mailing Address - Phone:351-224-9671
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR132394-8363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN209K1JOOtherBCBS
MN233677400Medicaid
MNHP32961OtherHEALTH PARTNERS
MNNA9021032953OtherPREFERRED ONE
MN171175OtherUCARE
MN01-73347OtherMEDICA
MN233677400Medicaid