Provider Demographics
NPI:1912698606
Name:JOHNSON, KIMBERLY JOYCE (RD, LD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOYCE
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 1:109 W 39TH ST APT 113
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-5022
Mailing Address - Country:US
Mailing Address - Phone:214-463-6535
Mailing Address - Fax:
Practice Address - Street 1:595 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4681
Practice Address - Country:US
Practice Address - Phone:415-800-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered