Provider Demographics
NPI:1003945254
Name:JOHNSON, CAROL W (MS RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SPURGEN DR
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-7808
Mailing Address - Country:US
Mailing Address - Phone:704-692-7727
Mailing Address - Fax:
Practice Address - Street 1:103 SPURGEN DR
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-7808
Practice Address - Country:US
Practice Address - Phone:704-692-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1434POtherPROVIDER NUMBER
NC2995071Medicare UPIN