Healthcare Provider Details

I. General information

NPI: 1356512040
Provider Name (Legal Business Name): GWENYTH L JOHNSON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 SEAGULL DR # NA
DULUTH GA
30096-3990
US

IV. Provider business mailing address

2925 SEAGULL DR
DULUTH GA
30096-3960
US

V. Phone/Fax

Practice location:
  • Phone: 704-238-9240
  • Fax:
Mailing address:
  • Phone: 470-238-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLD002373
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License NumberLD002373
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLD002373
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002373
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: