Provider Demographics
NPI:1467299693
Name:JOHNSON, ZACHERY SHANE (RD)
Entity type:Individual
Prefix:
First Name:ZACHERY
Middle Name:SHANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 BONNIE CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4124
Mailing Address - Country:US
Mailing Address - Phone:614-607-0015
Mailing Address - Fax:
Practice Address - Street 1:712 BONNIE CIR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4124
Practice Address - Country:US
Practice Address - Phone:614-607-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11525133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered