Provider Demographics
NPI:1679255350
Name:GANEM, JOHANNA P (RDN)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:P
Last Name:GANEM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 DOOMAR DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4805
Mailing Address - Country:US
Mailing Address - Phone:305-587-6631
Mailing Address - Fax:
Practice Address - Street 1:1901 DOOMAR DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4805
Practice Address - Country:US
Practice Address - Phone:305-587-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered