Provider Demographics
NPI:1699177170
Name:JOHNSON, CARLY MORGAN (RD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MORGAN
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 1:1045 N STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1219
Mailing Address - Country:US
Mailing Address - Phone:217-864-2084
Mailing Address - Fax:217-864-2324
Practice Address - Street 1:1045 N STATE HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1219
Practice Address - Country:US
Practice Address - Phone:217-864-2084
Practice Address - Fax:217-864-2324
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006295133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered