Provider Demographics
NPI:1114554060
Name:JOHNSON, KRISTEN (RD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
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 1:954 N SILVER WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-4582
Mailing Address - Country:US
Mailing Address - Phone:801-616-9213
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3328
Practice Address - Country:US
Practice Address - Phone:801-357-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5911399-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered