Provider Demographics
NPI:1275348112
Name:JOHNSON, ELLEN MARIE (RN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2595
Mailing Address - Country:US
Mailing Address - Phone:651-254-1611
Mailing Address - Fax:651-254-5216
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2595
Practice Address - Country:US
Practice Address - Phone:651-254-1611
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN784504163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse