Provider Demographics
NPI:1083022354
Name:JOHNSON, KELSEY KAY (RD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KAY
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 1:1295 BANDANA BLVD N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5126
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:
Practice Address - Street 1:673 WOODLAND SQUARE LOOP SE
Practice Address - Street 2:SUITE 330
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1066
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60408150133V00000X
86007053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered