Provider Demographics
NPI:1053116483
Name:EVERNORTH CLINIC, PLLC
Entity type:Organization
Organization Name:EVERNORTH CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CPNP-PC
Authorized Official - Phone:931-436-8197
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-0048
Mailing Address - Country:US
Mailing Address - Phone:763-284-1792
Mailing Address - Fax:763-205-5834
Practice Address - Street 1:5703 LACHMAN AVE NE STE 214
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-3973
Practice Address - Country:US
Practice Address - Phone:763-284-1877
Practice Address - Fax:763-205-5834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-18
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health