Provider Demographics
NPI:1447286216
Name:JOHNSON, KENNETH DEWAYNE (RD, LN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEWAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4645
Mailing Address - Country:US
Mailing Address - Phone:605-338-2009
Mailing Address - Fax:
Practice Address - Street 1:2501 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1305
Practice Address - Country:US
Practice Address - Phone:605-336-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0003133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered