Provider Demographics
NPI:1114890019
Name:JOHNSON, CASSIE RENEA (RDN, CPT)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:RENEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 BONNIE CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4124
Mailing Address - Country:US
Mailing Address - Phone:304-993-4800
Mailing Address - Fax:
Practice Address - Street 1:712 BONNIE CIR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4124
Practice Address - Country:US
Practice Address - Phone:304-993-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1922133V00000X
FLND12305133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered