Provider Demographics
NPI:1407249279
Name:JOHNSON, TERRA RACHELLE (MS, RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:RACHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:3830 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6920
Practice Address - Country:US
Practice Address - Phone:602-323-3344
Practice Address - Fax:602-323-3496
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL-56576174N00000X
AZ86277803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN