Provider Demographics
NPI:1164069951
Name:JOHNSON, TAMARA LYNN (MED, RD,LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MADRONA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97465-9552
Mailing Address - Country:US
Mailing Address - Phone:541-332-3861
Mailing Address - Fax:541-332-0250
Practice Address - Street 1:525 MADRONA AVE
Practice Address - Street 2:
Practice Address - City:PORT ORFORD
Practice Address - State:OR
Practice Address - Zip Code:97465-9552
Practice Address - Country:US
Practice Address - Phone:541-332-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10203616133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered