Provider Demographics
NPI:1508310277
Name:JOHNSON, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24705 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-6827
Mailing Address - Country:US
Mailing Address - Phone:225-687-9021
Mailing Address - Fax:
Practice Address - Street 1:24705 PLAZA DR
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-6827
Practice Address - Country:US
Practice Address - Phone:225-687-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2395133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered