Provider Demographics
NPI:1376125443
Name:JOHNSTON, KENNEDY LAUREN (RDN)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:LAUREN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GEKELER LN APT 39
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3489
Mailing Address - Country:US
Mailing Address - Phone:818-424-3792
Mailing Address - Fax:
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10213212133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered