Provider Demographics
NPI:1902897853
Name:JOHNSON, JANELLE L (MD)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45236208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
142738OtherU CARE
1679007OtherARAZ GRP AMERICA'S PPO
318J2JOOtherBLUE CROSS BLUE SHIELD
HP35801OtherHEALTH PARTNERS
1202293OtherMEDICA HEALTH PLANS
1032225OtherPREFERRED ONE
2130072OtherFIRST HEALTH PLAN
1032225OtherPREFERRED ONE