Provider Demographics
NPI:1164267290
Name:JOHNSON, HANNAH (RND)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RND
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:DISTERDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 LIGHTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3488
Mailing Address - Country:US
Mailing Address - Phone:423-290-7752
Mailing Address - Fax:
Practice Address - Street 1:100 LIGHTWOOD DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3488
Practice Address - Country:US
Practice Address - Phone:423-290-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000002570133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered