Provider Demographics
NPI:1104697564
Name:JOHNSON, COLETTE RAE (RN)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:RAE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5960 142ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5644
Mailing Address - Country:US
Mailing Address - Phone:763-843-1223
Mailing Address - Fax:
Practice Address - Street 1:5500 94TH AVE N OFC BUILDING
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1992
Practice Address - Country:US
Practice Address - Phone:763-843-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2185949163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health