Provider Demographics
NPI:1235742917
Name:JOHNSON, AMANDA MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
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 1:520 N OAKLEY BLVD APT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1427
Mailing Address - Country:US
Mailing Address - Phone:708-560-6265
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered