Provider Demographics
NPI:1407623481
Name:JOHNSON, KERRY LYNN (RDN)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:LYNN
Last Name:JOHNSON
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 1:2727 W BLUFF AVE APT 112
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-7012
Mailing Address - Country:US
Mailing Address - Phone:559-960-3157
Mailing Address - Fax:
Practice Address - Street 1:205 E RIVER PARK CIR STE 460
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-1585
Practice Address - Country:US
Practice Address - Phone:559-261-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA639580133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered