Provider Demographics
NPI:1508426156
Name:JOHNSON, BECKY ANN (LD)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2371 NE STEPHENS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1399
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:855-670-1788
Practice Address - Street 1:480 WARTAHOO LN
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9683
Practice Address - Country:US
Practice Address - Phone:541-839-1345
Practice Address - Fax:855-670-1791
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10200106133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered