Provider Demographics
NPI:1134442122
Name:JOHNSON, ELISSAVETA B (M S, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:ELISSAVETA
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:M S, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 SHADED OASIS LN
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6966
Mailing Address - Country:US
Mailing Address - Phone:706-506-5379
Mailing Address - Fax:
Practice Address - Street 1:601 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1202
Practice Address - Country:US
Practice Address - Phone:770-456-3249
Practice Address - Fax:770-456-3351
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003412133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered