Provider Demographics
NPI:1477222008
Name:JOHNSON, MARIE L (RDN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:L
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 1:1442 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2016
Mailing Address - Country:US
Mailing Address - Phone:201-952-5628
Mailing Address - Fax:
Practice Address - Street 1:2460 E MADRID AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1884
Practice Address - Country:US
Practice Address - Phone:417-814-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO86084578133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered