Healthcare Provider Details

I. General information

NPI: 1508426156
Provider Name (Legal Business Name): BECKY ANN JOHNSON LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

2371 NE STEPHENS ST STE 200
ROSEBURG OR
97470-1399
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-1396
  • Fax:
Mailing address:
  • Phone: 541-672-8533
  • Fax: 855-670-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number8606562
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10200106
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: