Provider Demographics
NPI:1164708947
Name:JOHNSON, AVA ANNETTE (RD)
Entity Type:Individual
Prefix:MS
First Name:AVA
Middle Name:ANNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AVA
Other - Middle Name:ANNETTE
Other - Last Name:CUTICCHIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1235 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4401
Mailing Address - Country:US
Mailing Address - Phone:910-433-3600
Mailing Address - Fax:910-433-3661
Practice Address - Street 1:1235 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4401
Practice Address - Country:US
Practice Address - Phone:910-433-3600
Practice Address - Fax:910-433-3661
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC620661133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered