MEDICARE: BROOKE ELIZABETH JOHNSON RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1669335055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ELIZABETH JOHNSON RD

Provider Business Mailing Address
First Line	:	4705 PROMINENT MESA VW APT 210
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-8675
Country	:	US
Telephone Number	:	337-853-4375
Fax Number	:

Provider Business Practice Location Address
First Line	:	4705 PROMINENT MESA VW APT 210
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-8675
Country	:	US
Telephone Number	:	337-853-4375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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