Provider Demographics
NPI:1295857886
Name:JOHNSON, KIMBERLY LOUISE (RDLD,CDE)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDLD,CDE
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:LOUISE
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDLD
Mailing Address - Street 1:750 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2341
Mailing Address - Country:US
Mailing Address - Phone:218-362-6608
Mailing Address - Fax:218-362-6617
Practice Address - Street 1:750 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2341
Practice Address - Country:US
Practice Address - Phone:218-362-6608
Practice Address - Fax:218-362-6617
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1748133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered