Healthcare Provider Details

I. General information

NPI: 1699714923
Provider Name (Legal Business Name): SARA JOHNSON RD, LD, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8383
  • Fax:
Mailing address:
  • Phone: 612-625-8690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1944
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: