Provider Demographics
NPI:1811393580
Name:JOHNSON, GLENDA (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5042
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70069-5042
Mailing Address - Country:US
Mailing Address - Phone:504-975-3657
Mailing Address - Fax:
Practice Address - Street 1:2021 PERDIDO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1352
Practice Address - Country:US
Practice Address - Phone:504-975-3657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered