Provider Demographics
NPI:1780090761
Name:JOHNSON, DANIEL R (RDN, LDN, CEP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RDN, LDN, CEP
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN, LDN, CEP
Mailing Address - Street 1:P.O. DRAWER PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:IHS PINON HEALTH CENTER NAVAJO RT 4
Practice Address - Street 2:
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510
Practice Address - Country:US
Practice Address - Phone:928-674-7166
Practice Address - Fax:928-674-7705
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3643133N00000X, 133V00000X
CA1053031133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist