Basic Information
| Provider Information | |||||||||
| NPI: | 1487734299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICHELLE | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | R.D, L.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1585 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT POLK | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714595102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1585 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT POLK | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714595102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375313349 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND 3309 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.