Provider Demographics
NPI:1689008062
Name:JOHNSON, LEOLA (RN, CNS)
Entity Type:Individual
Prefix:
First Name:LEOLA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13021 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-7439
Mailing Address - Country:US
Mailing Address - Phone:218-829-9307
Mailing Address - Fax:218-829-7649
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN0917363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health