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NPI Code Detail

MEDICARE: MRS. CHERYL GAINES JOHNSON RD/LD

MEDICARE: MRS. CHERYL GAINES JOHNSON RD/LD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian1070OK

General Provider Information

NPI Number : 1134117534
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CHERYL GAINES JOHNSON RD/LD
Provider Business Mailing Address
First Line : 301 J T STITES BLVD
Second Line :
City : SALLISAW
State : OK
Zip : 74955-9302
Country : US
Telephone Number : 918-774-1490
Fax Number : 918-774-1425
Provider Business Practice Location Address
First Line : 301 J T STITES BLVD
Second Line :
City : SALLISAW
State : OK
Zip : 74955-9302
Country : US
Telephone Number : 918-774-1490
Fax Number : 918-774-1425
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2005
Last Update Date : 07/08/2007

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