Provider Demographics
NPI:1215610514
Name:JOHNSON, MCKENNA NOELLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:NOELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 PRAIRIE FLOWER RD
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1956
Mailing Address - Country:US
Mailing Address - Phone:651-600-6377
Mailing Address - Fax:
Practice Address - Street 1:1111 HOLCOMBE ST S
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5736
Practice Address - Country:US
Practice Address - Phone:651-241-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist