Provider Demographics
NPI:1093019531
Name:JOHNSON, SHANTAY M
Entity Type:Individual
Prefix:
First Name:SHANTAY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 PARKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:SEAGOVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75159-2334
Mailing Address - Country:US
Mailing Address - Phone:281-650-9130
Mailing Address - Fax:
Practice Address - Street 1:1624 PARKHAVEN DRIVE
Practice Address - Street 2:
Practice Address - City:SEAGOVILLE
Practice Address - State:TX
Practice Address - Zip Code:75159
Practice Address - Country:US
Practice Address - Phone:281-650-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-24
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372600000XNursing Service Related ProvidersAdult Companion
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child