Provider Demographics
NPI:1497924088
Name:JOHNSON, CYNTHIA A (CD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CD
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 1581
Mailing Address - Street 2:
Mailing Address - City:MATTAWA
Mailing Address - State:WA
Mailing Address - Zip Code:99349-0960
Mailing Address - Country:US
Mailing Address - Phone:509-932-4499
Mailing Address - Fax:509-932-5363
Practice Address - Street 1:210 GOVERNMENT ROAD
Practice Address - Street 2:
Practice Address - City:MATTAWA
Practice Address - State:WA
Practice Address - Zip Code:99349-0960
Practice Address - Country:US
Practice Address - Phone:509-932-4499
Practice Address - Fax:509-932-5363
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered