Healthcare Provider Details

I. General information

NPI: 1932456589
Provider Name (Legal Business Name): ROSE M JOHNSON RD, LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 KOCH DR
BISMARCK ND
58503-1240
US

IV. Provider business mailing address

2019 KOCH DR
BISMARCK ND
58503-1240
US

V. Phone/Fax

Practice location:
  • Phone: 715-571-0355
  • Fax:
Mailing address:
  • Phone: 715-571-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number950
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number950
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number950
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: