Provider Demographics
NPI:1437561511
Name:JOHANSEN, LAURA (MS, RD, LMNT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:MS, RD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 N 156TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3410 N 156TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-2020
Practice Address - Country:US
Practice Address - Phone:402-493-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1140133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered