Provider Demographics
NPI:1184493355
Name:JOHNSON, KELSEY NICOLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:NICOLE
Other - Last Name:RUDSINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3555 WILLOW LAKE BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4465
Mailing Address - Country:US
Mailing Address - Phone:952-431-5330
Mailing Address - Fax:
Practice Address - Street 1:3555 WILLOW LAKE BLVD STE 290
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-4465
Practice Address - Country:US
Practice Address - Phone:952-431-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11143363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health