Provider Demographics
NPI:1417236159
Name:JOHNSON, ERICA (MPH, RD, LD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPH, 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:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0489
Mailing Address - Country:US
Mailing Address - Phone:503-842-3900
Mailing Address - Fax:
Practice Address - Street 1:801 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141
Practice Address - Country:US
Practice Address - Phone:503-842-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10144495133V00000X
1003747133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered