Provider Demographics
NPI:1356512040
Name:JOHNSON, GWENYTH L (RD, LD)
Entity Type:Individual
Prefix:
First Name:GWENYTH
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5238 PEACHTREE RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2718
Mailing Address - Country:US
Mailing Address - Phone:770-455-7602
Mailing Address - Fax:770-488-9285
Practice Address - Street 1:5238 PEACHTREE RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-2718
Practice Address - Country:US
Practice Address - Phone:770-455-7602
Practice Address - Fax:770-488-9285
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002373133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBB2WMedicare PIN