Provider Demographics
NPI:1891590642
Name:JOHNSON, MATISSE LELA
Entity type:Individual
Prefix:
First Name:MATISSE
Middle Name:LELA
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2839
Mailing Address - Country:US
Mailing Address - Phone:612-598-2550
Mailing Address - Fax:612-598-2550
Practice Address - Street 1:6813 5TH ST N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-2839
Practice Address - Country:US
Practice Address - Phone:612-598-2550
Practice Address - Fax:612-598-2550
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202501-13374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula