Provider Demographics
NPI:1396861290
Name:JOHNSON, MARSHA A (CDN)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 BRICK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-9739
Mailing Address - Country:US
Mailing Address - Phone:315-524-6225
Mailing Address - Fax:
Practice Address - Street 1:3071 COUNTY COMPLEX DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9505
Practice Address - Country:US
Practice Address - Phone:585-394-4620
Practice Address - Fax:585-394-1987
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0032061133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered