Healthcare Provider Details

I. General information

NPI: 1407249279
Provider Name (Legal Business Name): TERRA RACHELLE JOHNSON MS, RDN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 E VAN BUREN ST
PHOENIX AZ
85008-6920
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 1600
PHOENIX AZ
85012-2908
US

V. Phone/Fax

Practice location:
  • Phone: 602-323-3344
  • Fax: 602-323-3496
Mailing address:
  • Phone: 602-323-3344
  • Fax: 602-323-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86277803
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-56576
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: