Provider Demographics
NPI:1225369366
Name:JOHNSON, RACHELLE (RD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
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 1:1200 E MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63834-1336
Mailing Address - Country:US
Mailing Address - Phone:573-683-2191
Mailing Address - Fax:573-683-6539
Practice Address - Street 1:1200 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MO
Practice Address - Zip Code:63834-1336
Practice Address - Country:US
Practice Address - Phone:573-683-2191
Practice Address - Fax:573-683-6539
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004023246133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO357290501Medicaid