Provider Demographics
NPI:1891109989
Name:JOHNSON, STEPHANI ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANI
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANI
Other - Middle Name:ANN
Other - Last Name:SEYMOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-853-8727
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MS11102F
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-254-5216
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant