Provider Demographics
NPI:1932456589
Name:JOHNSON, ROSE M (RD, LRD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 KOCH DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1240
Mailing Address - Country:US
Mailing Address - Phone:715-571-0355
Mailing Address - Fax:
Practice Address - Street 1:2019 KOCH DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1240
Practice Address - Country:US
Practice Address - Phone:715-571-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND950133VN1005X, 133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered