Provider Demographics
NPI:1376248849
Name:JOHNSON, PAMELA (RD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
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 1:29970 TECHNOLOGY DR STE 118
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2647
Mailing Address - Country:US
Mailing Address - Phone:508-410-2628
Mailing Address - Fax:
Practice Address - Street 1:29970 TECHNOLOGY DR STE 118
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2647
Practice Address - Country:US
Practice Address - Phone:508-410-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86020548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered