Provider Demographics
NPI:1851795116
Name:JOHNKE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JOHNKE
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 1:500 E FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5689
Mailing Address - Country:US
Mailing Address - Phone:701-355-1540
Mailing Address - Fax:701-221-6883
Practice Address - Street 1:500 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5689
Practice Address - Country:US
Practice Address - Phone:701-355-1540
Practice Address - Fax:701-221-6883
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered