Provider Demographics
NPI:1710636352
Name:JOHNSON, SAVANNAH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:
Other - Last Name:PERSAUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3155 INDIANA AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3109
Mailing Address - Country:US
Mailing Address - Phone:612-720-6566
Mailing Address - Fax:
Practice Address - Street 1:2442 MOUNDS VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-1478
Practice Address - Country:US
Practice Address - Phone:763-316-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program