Basic Information
| Provider Information | |||||||||
| NPI: | 1982005732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CLEANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD,CD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 PRADERA CT | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993014619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095423052 | ||||||||
| FaxNumber: | 5095423053 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 N 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095477704 | ||||||||
| FaxNumber: | 5095423053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI60470392 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DI60470392 | 01 | WA | DIETITIAN CERTIFICATION | OTHER |