Provider Demographics
NPI:1982005732
Name:JOHNSON, CLEANNE (RD,CD)
Entity Type:Individual
Prefix:MRS
First Name:CLEANNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 PRADERA CT
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4619
Mailing Address - Country:US
Mailing Address - Phone:509-542-3052
Mailing Address - Fax:509-542-3053
Practice Address - Street 1:520 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5257
Practice Address - Country:US
Practice Address - Phone:509-547-7704
Practice Address - Fax:509-542-3053
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60470392133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI60470392OtherDIETITIAN CERTIFICATION