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NPI Code Detail

MEDICARE: MRS. ELISSAVETA B JOHNSON M. S., R.D., L.D.

MEDICARE: MRS. ELISSAVETA B JOHNSON M. S., R.D., L.D.
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 DietitianLD003412GA

General Provider Information

NPI Number : 1134442122
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ELISSAVETA B JOHNSON M. S., R.D., L.D.
Provider Business Mailing Address
First Line : 4012 SHADED OASIS LN
Second Line :
City : VILLA RICA
State : GA
Zip : 30180-6966
Country : US
Telephone Number : 706-506-5379
Fax Number :
Provider Business Practice Location Address
First Line : 601 DALLAS HWY
Second Line :
City : VILLA RICA
State : GA
Zip : 30180-1202
Country : US
Telephone Number : 770-456-3249
Fax Number : 770-456-3351
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2010
Last Update Date : 03/05/2010

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