Provider Demographics
NPI:1558044123
Name:JOHNSON, KYLIE (RD)
Entity Type:Individual
Prefix:
First Name:KYLIE
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 1:5735 MEEKER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1186
Mailing Address - Country:US
Mailing Address - Phone:937-548-9680
Mailing Address - Fax:937-548-2087
Practice Address - Street 1:1101 JACKSON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1395
Practice Address - Country:US
Practice Address - Phone:937-547-2319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.7703133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered