Provider Demographics
NPI:1669741526
Name:JOHNSON, TARA BETH (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 WILSON STREET
Mailing Address - Street 2:REYNOLDS ARMY COMMUNITY HOSPITAL
Mailing Address - City:FT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:75303
Mailing Address - Country:US
Mailing Address - Phone:580-558-2825
Mailing Address - Fax:
Practice Address - Street 1:4301 WILSON STREET
Practice Address - Street 2:REYNOLDS ARMY COMMUNITY HOSPITAL
Practice Address - City:FT SILL
Practice Address - State:OK
Practice Address - Zip Code:75303
Practice Address - Country:US
Practice Address - Phone:580-558-2825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1878133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
243345OtherACADEMY OF LACTATION POLICY AND PRACTICE