Provider Demographics
NPI:1114470077
Name:JOHNSON, SHAKISHA
Entity Type:Individual
Prefix:
First Name:SHAKISHA
Middle Name:
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 1:1882 CAPITAL CIR NE
Mailing Address - Street 2:STE 105
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4530
Mailing Address - Country:US
Mailing Address - Phone:850-656-2320
Mailing Address - Fax:
Practice Address - Street 1:1882 CAPITAL CIR NE
Practice Address - Street 2:STE 105
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4530
Practice Address - Country:US
Practice Address - Phone:850-656-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100057522253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency