Provider Demographics
NPI:1700972460
Name:JOHNSON, GLENYS S (RD, LD)
Entity type:Individual
Prefix:
First Name:GLENYS
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:GLENYS
Other - Middle Name:S
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:1248 STEVENS RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211
Mailing Address - Country:US
Mailing Address - Phone:214-331-6043
Mailing Address - Fax:214-456-6287
Practice Address - Street 1:1935 MOTOR STREET
Practice Address - Street 2:CLINICAL NUTRITION
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-456-2182
Practice Address - Fax:214-456-6287
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05235133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX847744OtherREGISTERED DIETITIAN
TXDT05235OtherLICENSED DIETITIAN