Provider Demographics
NPI:1740882158
Name:JOHNSON, KOURTNEY J (RD, LD)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:J
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 1:3962 143RD ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4060
Mailing Address - Country:US
Mailing Address - Phone:612-214-1635
Mailing Address - Fax:
Practice Address - Street 1:3962 143RD ST W
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-4060
Practice Address - Country:US
Practice Address - Phone:612-214-1635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered