Provider Demographics
NPI:1053719237
Name:JOHNSON, LISELLE MARIE (CNP)
Entity type:Individual
Prefix:
First Name:LISELLE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HEWITT BLVD
Mailing Address - Street 2:RED WING
Mailing Address - City:MN
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2848
Mailing Address - Country:US
Mailing Address - Phone:507-377-6285
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 1577363LF0000X
MN1577363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily