Kyrsten Ann Johnson, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

60466 Issued in MN

Practice address

12000 Elm Creek Blvd N
Suite 250
Maple Grove, MN 55369-7073

Phone

(952) 401-8300

Fax

(952) 401-8242

NPI assigned

Apr 2, 2013

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Kyrsten Ann Kelley Former name

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• South Lake Clinic, P.a.

  dba South Lake Pediatrics

  • Pediatrics Physician
  • Minnetonka, MN
  • NPI 1427027184
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1364860800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1505779200000",
    "number": "1487997037",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17705 HUTCHINS DR.",
            "address_2": "# 250",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "55345",
            "telephone_number": "952-401-8300",
            "fax_number": "952-401-8242"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N",
            "address_2": "SUITE 250",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697073",
            "telephone_number": "952-401-8300",
            "fax_number": "952-401-8242"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "KYRSTEN",
        "middle_name": "ANN",
        "name_prefix": "Mrs.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-04-02",
        "last_updated": "2017-09-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MN",
            "license": "60466",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KYRSTEN",
            "last_name": "KELLEY",
            "middle_name": "ANN",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Jennifer Marie Johnson, LPCC
• Jewel Johnson
• Karen Marie Johnson, PT
• Keith Johnson, MD
• Keith Michael Johnson, DC
• Madison Anne Johnson
• Mary Johnson, LMT
• Michael Hans Johnson, MD
• Natalie Nicole Johnson, APRN, CNP
• Nicholas Roy Johnson, PA-C

• Pediatrics Physician in Maple Grove, MN
• Providers in Maple Grove, MN by specialty
• Pediatrics Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.