Provider Demographics
NPI:1205618642
Name:JOHNSON, MARY JANE (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HOLBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367 DELLWOOD RD STE D
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-3153
Practice Address - Country:US
Practice Address - Phone:828-558-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005916133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered