Provider Demographics
NPI:1801173893
Name:JOHNSON, KASEY E (DO)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2416
Mailing Address - Country:US
Mailing Address - Phone:701-293-4113
Mailing Address - Fax:701-293-4109
Practice Address - Street 1:1919 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2416
Practice Address - Country:US
Practice Address - Phone:701-293-4113
Practice Address - Fax:701-293-4109
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 390200000X
NDRL17452390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker