Provider Demographics
NPI:1134300213
Name:JOHNSON, GRACE ELIZABETH (RD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ELIZABETH
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 1:2261 EASTRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-7720
Mailing Address - Country:US
Mailing Address - Phone:805-981-8110
Mailing Address - Fax:805-981-8110
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:SUITE 292
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-449-4494
Practice Address - Fax:626-449-4474
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL894433133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMNT894433Medicare PIN