Provider Demographics
NPI:1003599986
Name:JOHANSEN, SAMANTHA N (RD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:N
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 A ST APT H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-7023
Mailing Address - Country:US
Mailing Address - Phone:619-607-5536
Mailing Address - Fax:
Practice Address - Street 1:2741 A ST APT H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-7023
Practice Address - Country:US
Practice Address - Phone:619-607-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered