Provider Demographics
NPI:1144436189
Name:JOHNSON, MARY AGNES
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AGNES
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 1:705 KNUTI DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705
Mailing Address - Country:US
Mailing Address - Phone:218-229-8936
Mailing Address - Fax:218-229-2666
Practice Address - Street 1:705 KNUTI DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705
Practice Address - Country:US
Practice Address - Phone:218-229-8936
Practice Address - Fax:218-229-2666
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant