Healthcare Provider Details

I. General information

NPI: 1447286216
Provider Name (Legal Business Name): KENNETH DEWAYNE JOHNSON R.D., L.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W 22ND ST
SIOUX FALLS SD
57105-1305
US

IV. Provider business mailing address

812 S LAKE AVE
SIOUX FALLS SD
57104-4645
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-3230
  • Fax:
Mailing address:
  • Phone: 605-338-2009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0003
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: