Provider Demographics
NPI:1871070995
Name:JOHANSEN, MAIJA LIV
Entity type:Individual
Prefix:
First Name:MAIJA
Middle Name:LIV
Last Name:JOHANSEN
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 1:100 WOODRUFF CIR NE STE P375
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1020
Mailing Address - Country:US
Mailing Address - Phone:404-727-5655
Mailing Address - Fax:404-727-0045
Practice Address - Street 1:3316 W 66TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2532
Practice Address - Country:US
Practice Address - Phone:952-920-3808
Practice Address - Fax:952-920-8899
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-21
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN78808207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program