Provider Demographics
NPI:1003434176
Name:JOHNSON, SHARONDA SHANISE (NURSING ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:SHARONDA
Middle Name:SHANISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSING ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7420
Mailing Address - Country:US
Mailing Address - Phone:407-902-1307
Mailing Address - Fax:
Practice Address - Street 1:325 E 15TH ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-7114
Practice Address - Country:US
Practice Address - Phone:321-316-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL124374U00000X
FL372600000X, 376J00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110610700Medicaid