Provider Demographics
NPI:1952993669
Name:JOHNSON, CARLI JO
Entity Type:Individual
Prefix:
First Name:CARLI
Middle Name:JO
Last Name:JOHNSON
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 1:328 N ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:COLMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57017-2029
Mailing Address - Country:US
Mailing Address - Phone:605-864-0918
Mailing Address - Fax:
Practice Address - Street 1:911 E 20TH ST STE 700
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1049
Practice Address - Country:US
Practice Address - Phone:605-334-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner