Provider Demographics
NPI:1366074494
Name:JOHNSON, MARIAH JANE (RDN, LD)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:JANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:LEDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:14995 COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-8747
Mailing Address - Country:US
Mailing Address - Phone:320-260-1247
Mailing Address - Fax:
Practice Address - Street 1:14995 COUNTRY RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-8747
Practice Address - Country:US
Practice Address - Phone:320-260-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2587133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered