Provider Demographics
NPI:1568703601
Name:JOHNSON, GRACE P (MA, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 NW 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1863
Mailing Address - Country:US
Mailing Address - Phone:954-443-0222
Mailing Address - Fax:
Practice Address - Street 1:19590 OLD CUTLER RD
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8048
Practice Address - Country:US
Practice Address - Phone:786-466-3500
Practice Address - Fax:786-466-3889
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3260133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered