Provider Demographics
NPI:1386425551
Name:JOHNSON, RUSS-EM (RN, CCRN, CMC)
Entity type:Individual
Prefix:
First Name:RUSS-EM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, CCRN, CMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1980
Mailing Address - Country:US
Mailing Address - Phone:763-439-9854
Mailing Address - Fax:
Practice Address - Street 1:5930 CORNERSTONE CT W STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3772
Practice Address - Country:US
Practice Address - Phone:866-687-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2307099163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse