Healthcare Provider Details

I. General information

NPI: 1780628172
Provider Name (Legal Business Name): ANNETTE P. JOHNSON M.S.,R.D.,L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 SPRING VALLEY DR
HUNTINGTON WV
25704-9588
US

IV. Provider business mailing address

207 PRIVATE DRIVE 10461
PROCTORVILLE OH
45669-8028
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-6755
  • Fax: 304-429-0264
Mailing address:
  • Phone: 304-429-6755
  • Fax: 304-429-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0447
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: