Provider Demographics
NPI:1306839956
Name:JOHNSON, CRYSTAL J (MS, RD, CDE, CD, LD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RD, CDE, CD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11608 N KATHY DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-2725
Mailing Address - Country:US
Mailing Address - Phone:509-869-2330
Mailing Address - Fax:
Practice Address - Street 1:11608 N KATHY DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-2725
Practice Address - Country:US
Practice Address - Phone:509-869-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001258133V00000X
MDDX3074133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8299679Medicaid
P56872Medicare UPIN
WAAB28420Medicare ID - Type Unspecified