Provider Demographics
NPI:1104309301
Name:JOHNSON, MAGGIE K (RD)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:K
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 DOWELL SPRINGS BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909
Mailing Address - Country:US
Mailing Address - Phone:865-637-8812
Mailing Address - Fax:865-637-8865
Practice Address - Street 1:1450 DOWELL SPRINGS BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909
Practice Address - Country:US
Practice Address - Phone:865-637-8812
Practice Address - Fax:865-637-8865
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ045134Medicaid