Provider Demographics
NPI:1033432950
Name:JOHNSON, SHANNAH L (RD)
Entity Type:Individual
Prefix:
First Name:SHANNAH
Middle Name:L
Last Name:JOHNSON
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 1:2675 GRAND CONCOURSE
Mailing Address - Street 2:#4F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3745
Mailing Address - Country:US
Mailing Address - Phone:612-360-1491
Mailing Address - Fax:
Practice Address - Street 1:2675 GRAND CONCOURSE
Practice Address - Street 2:#4F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3745
Practice Address - Country:US
Practice Address - Phone:612-360-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY885503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered