Provider Demographics
NPI:1134117534
Name:JOHNSON, CHERYL GAINES (RD/LD)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:GAINES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 J T STITES BLVD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-9302
Mailing Address - Country:US
Mailing Address - Phone:918-774-1490
Mailing Address - Fax:918-774-1425
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-774-1490
Practice Address - Fax:918-774-1425
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1070133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered