Provider Demographics
NPI:1396722674
Name:JOHNSON-RAUEN, NANCY L (PT, DPT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:JOHNSON-RAUEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:L
Other - Last Name:JONSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:1629 BROADWAY AVE N
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4103
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
MN5018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN650002400Medicare PIN
OTH000Medicare UPIN
OTH000Medicare UPIN
MN650000773Medicare ID - Type Unspecified