Provider Demographics
NPI:1760236087
Name:JOHNSON, SANDRA LEE (RD, LD, CDCES)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 HAGERMAN RD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3547
Mailing Address - Country:US
Mailing Address - Phone:281-217-4699
Mailing Address - Fax:
Practice Address - Street 1:2320 HAGERMAN RD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-3547
Practice Address - Country:US
Practice Address - Phone:281-217-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86169488133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered