Provider Demographics
NPI:1487841979
Name:JOHANSEN, LAURENCE MIKKEL (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:MIKKEL
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, CD
Mailing Address - Street 1:W137N6915 MANOR HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-5272
Mailing Address - Country:US
Mailing Address - Phone:262-532-0293
Mailing Address - Fax:
Practice Address - Street 1:12425 KNOLL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2657
Practice Address - Country:US
Practice Address - Phone:262-780-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2045-29133V00000X
963363133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered