Basic Information
| Provider Information | |||||||||
| NPI: | 1164069951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MED, RD,LD,CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 MADRONA AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ORFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974659552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413323861 | ||||||||
| FaxNumber: | 5413320250 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 MADRONA AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ORFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974659552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413323861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2019 | ||||||||
| LastUpdateDate: | 11/29/2019 | ||||||||
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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 | LD-D-10203616 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.