Provider Demographics
NPI:1689742330
Name:LARSON, JOHANNA B (RD)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:B
Last Name:LARSON
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 1:43500 MIGIZI DR
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-2241
Mailing Address - Country:US
Mailing Address - Phone:800-709-6445
Mailing Address - Fax:
Practice Address - Street 1:43500 MIGIZI DR
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-2241
Practice Address - Country:US
Practice Address - Phone:800-709-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2250133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered