Provider Demographics
NPI:1730310806
Name:JOHNSON, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:410 DOUGLASS ST
Mailing Address - Street 2:#2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-4503
Mailing Address - Country:US
Mailing Address - Phone:718-398-1216
Mailing Address - Fax:
Practice Address - Street 1:410 DOUGLASS ST
Practice Address - Street 2:#2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-4503
Practice Address - Country:US
Practice Address - Phone:718-398-1216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered