Provider Demographics
NPI:1760135826
Name:JOHNSON, CAROLYN (LPN)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 HARBOR LN N APT 6-303
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-8854
Mailing Address - Country:US
Mailing Address - Phone:208-699-1276
Mailing Address - Fax:
Practice Address - Street 1:3333 HARBOR LN N APT 6-303
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-8854
Practice Address - Country:US
Practice Address - Phone:208-699-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN818308164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse