Provider Demographics
NPI:1033855416
Name:JOHNSON, KRISTA MARIE (CNM, APRN)
Entity type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3601 KIPLING AVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4817
Mailing Address - Country:US
Mailing Address - Phone:901-343-7873
Mailing Address - Fax:
Practice Address - Street 1:3033 EXCELSIOR BLVD STE 585
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-6400
Practice Address - Country:US
Practice Address - Phone:612-345-5920
Practice Address - Fax:844-562-6828
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK191560363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology