Provider Demographics
NPI:1013141100
Name:DONG, JOHANNA M (MA, RD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:DONG
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 ESTRELLA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2940
Mailing Address - Country:US
Mailing Address - Phone:650-703-6090
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3856
Practice Address - Country:US
Practice Address - Phone:650-455-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA931795133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education