Basic Information
| Provider Information | |||||||||
| NPI: | 1598284325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CATES | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18 RURAL PL | ||||||||
| Address2: | |||||||||
| City: | DELMAR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120541104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184281405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 391 MYRTLE AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182624942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 86049965 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 141338310 | 05 | NY | MEDICAID |