Provider Demographics
NPI:1770110777
Name:JOHNSTON, STEFFANI NICOLE
Entity type:Individual
Prefix:
First Name:STEFFANI
Middle Name:NICOLE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEFFANI
Other - Middle Name:NICOLE
Other - Last Name:JOHNSTON MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:2405 8TH ST S STE 200
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4200
Practice Address - Country:US
Practice Address - Phone:218-331-4866
Practice Address - Fax:218-331-4967
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
NDPAC0837363A00000X
MN14462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical