Provider Demographics
NPI:1083841803
Name:JOHNSON, KATHRYN E (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LAYFAIR DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 LAYFAIR DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9717
Practice Address - Country:US
Practice Address - Phone:601-939-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1374133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered