Healthcare Provider Details

I. General information

NPI: 1780077024
Provider Name (Legal Business Name): PRISCILLA RAE JOHNSON LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 29TH ST NW
WASHINGTON DC
20015-1332
US

IV. Provider business mailing address

5316 29TH ST NW
WASHINGTON DC
20015-1332
US

V. Phone/Fax

Practice location:
  • Phone: 202-510-1164
  • Fax:
Mailing address:
  • Phone: 202-510-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNU100000165
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: