Provider Demographics
NPI:1821456930
Name:JOHNSON, KAILA E
Entity Type:Individual
Prefix:
First Name:KAILA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 E FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7446
Mailing Address - Country:US
Mailing Address - Phone:239-284-3220
Mailing Address - Fax:
Practice Address - Street 1:3041 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7446
Practice Address - Country:US
Practice Address - Phone:239-284-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61188977132700000X, 133V00000X
NCL006372133V00000X
UT12529665-4901133V00000X
CA86010388133V00000X
FLND10310133V00000X
KY269357133V00000X
MO2021019201133V00000X
OR10213181133V00000X
NV39024-DI-3133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager