{
"Npi": {
"NPI": "1508426156",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "JOHNSON",
"FirstName": "BECKY",
"MiddleName": "ANN",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "LD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2371 NE STEPHENS ST STE 200",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ROSEBURG",
"MailingAddressStateName": "OR",
"MailingAddressPostalCode": "97470-1399",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "541-672-8533",
"MailingAddressFaxNumber": "855-670-1788",
"FirstLinePracticeLocationAddress": "9605 GRAND RONDE RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GRAND RONDE",
"PracticeLocationAddressStateName": "OR",
"PracticeLocationAddressPostalCode": "97347-9712",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "503-879-1396",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/17/2019",
"LastUpdateDate": "10/10/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "133N00000X",
"TaxonomyName": "Nutritionist",
"LicenseNumber": "8606562",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "133V00000X",
"TaxonomyName": "Registered Dietitian",
"LicenseNumber": "10200106",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}