Provider Demographics
NPI:1629611033
Name:AYERS, JOHANNA CLARA (CNP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:CLARA
Last Name:AYERS
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 1:2925 DAKOTA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1834
Mailing Address - Country:US
Mailing Address - Phone:952-999-1233
Mailing Address - Fax:
Practice Address - Street 1:4656 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4938
Practice Address - Country:US
Practice Address - Phone:952-929-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily