Provider Demographics
NPI:1609967892
Name:JOHNSON, LISA ANN (MS,RD,CSG, LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS,RD,CSG, LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 BUMP GATE RD
Mailing Address - Street 2:
Mailing Address - City:PIPE CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:78063-5306
Mailing Address - Country:US
Mailing Address - Phone:830-510-4766
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-616-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02095133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered