Basic Information
| Provider Information | |||||||||
| NPI: | 1558884304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LRD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | GRACEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562404845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207487243 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2017 | ||||||||
| LastUpdateDate: | 07/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3438 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.