Provider Demographics
NPI:1871378273
Name:JOHNSON, MARIAH KELLEY
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:KELLEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 SCOTT TRAIL
Mailing Address - Street 2:110
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122
Mailing Address - Country:US
Mailing Address - Phone:651-454-1000
Mailing Address - Fax:
Practice Address - Street 1:4590 SCOTT TRAIL
Practice Address - Street 2:110
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:651-454-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist