Provider Demographics
NPI:1487201703
Name:JOHNSON, MARY DANIEL (RD)
Entity Type:Individual
Prefix:
First Name:MARY DANIEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 CLAY EDWARDS DR STE 600
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3274
Mailing Address - Country:US
Mailing Address - Phone:816-691-5048
Mailing Address - Fax:816-346-7039
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 600
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3274
Practice Address - Country:US
Practice Address - Phone:816-691-5048
Practice Address - Fax:816-346-7039
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1935133V00000X
MO2021034269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered