Provider Demographics
NPI:1366953911
Name:JOHNSON, STEPHANY (RD)
Entity type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 E HALLOCK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-9545
Mailing Address - Country:US
Mailing Address - Phone:309-360-0659
Mailing Address - Fax:
Practice Address - Street 1:8603 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1631
Practice Address - Country:US
Practice Address - Phone:309-226-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-22
Last Update Date:2017-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered