Healthcare Provider Details

I. General information

NPI: 1396836003
Provider Name (Legal Business Name): MARY JO JOHNSON RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE VETERANS AFFAIRS MEDICAL CENTER
MARTINSBURG WV
25405
US

IV. Provider business mailing address

100 W. NORTH AVE
WINCHESTER VA
22601
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax: 304-262-7435
Mailing address:
  • Phone: 540-662-0754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number716432
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: