Provider Demographics
NPI:1134785652
Name:JOHNSON, KRISTINA MARIE
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-803-5163
Mailing Address - Fax:513-636-5887
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-803-5163
Practice Address - Fax:513-636-5887
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X390200000X
OHLD.7097133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program