Provider Demographics
NPI:1720654056
Name:JOHNSON DAVIS, DININA
Entity Type:Individual
Prefix:MS
First Name:DININA
Middle Name:
Last Name:JOHNSON DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1155
Mailing Address - Country:US
Mailing Address - Phone:952-688-9499
Mailing Address - Fax:
Practice Address - Street 1:1615 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1155
Practice Address - Country:US
Practice Address - Phone:952-688-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7374559163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7374559Medicaid