Provider Demographics
NPI:1184324386
Name:JOHNSTON, DOMINIQUE SHOWMAKER (RD LDN)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:SHOWMAKER
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:J
Other - Last Name:SHOWMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LDN
Mailing Address - Street 1:55 MEADOWFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3043
Mailing Address - Country:US
Mailing Address - Phone:215-200-1047
Mailing Address - Fax:
Practice Address - Street 1:55 MEADOWFIELD DR
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3043
Practice Address - Country:US
Practice Address - Phone:215-200-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006364133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86084794OtherCOMMISSION ON DIETETIC REGISTRATION CDR