Provider Demographics
NPI:1649627902
Name:JOHNSTON, STEPHANIE (MS, LN)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MS, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 RIO RANCHO DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1570
Mailing Address - Country:US
Mailing Address - Phone:505-896-8600
Mailing Address - Fax:
Practice Address - Street 1:1721 RIO RANCHO DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1570
Practice Address - Country:US
Practice Address - Phone:505-896-8600
Practice Address - Fax:505-896-8687
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLN-1082133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist