MEDICARE: MRS. SARAH LEWIS JOHANSON RD

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
1	133V00000X	Registered Dietitian	DT84182	TX
2	133V00000X	Registered Dietitian	1897	AR

General Provider Information

NPI Number	:	1487529509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARAH LEWIS JOHANSON RD

Provider Business Mailing Address
First Line	:	2448 N EAST OAKS DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-6107
Country	:	US
Telephone Number	:	817-454-8933
Fax Number	:

Provider Business Practice Location Address
First Line	:	2448 N EAST OAKS DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-6107
Country	:	US
Telephone Number	:	817-454-8933
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2025
Last Update Date	:	10/08/2025

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