Provider Demographics
NPI:1245823434
Name:JOHNSON, GWEN GLORIA (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:GLORIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:PEPPERELL
Mailing Address - State:MA
Mailing Address - Zip Code:01463-4206
Mailing Address - Country:US
Mailing Address - Phone:978-257-3962
Mailing Address - Fax:
Practice Address - Street 1:25 ASHLEY ST
Practice Address - Street 2:
Practice Address - City:PEPPERELL
Practice Address - State:MA
Practice Address - Zip Code:01463-4206
Practice Address - Country:US
Practice Address - Phone:978-257-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty