Basic Information
| Provider Information | |||||||||
| NPI: | 1780293696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, CD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BIERHALS | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDN, CD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | W2857 CTY RD E | ||||||||
| Address2: | |||||||||
| City: | CECIL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541119446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2854 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2020 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 338229 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.