Provider Demographics
NPI:1174279848
Name:EARLE, JOHANNA LEIGH
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:LEIGH
Last Name:EARLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MANSEAU ST UNIT 209
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1599
Mailing Address - Country:US
Mailing Address - Phone:860-338-5863
Mailing Address - Fax:
Practice Address - Street 1:10 MANSEAU ST UNIT 209
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1599
Practice Address - Country:US
Practice Address - Phone:860-338-5863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist