Provider Demographics
NPI:1154081131
Name:JOHNSON, CHANTELLE SHANEKA (NP)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:SHANEKA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14151 SW 275TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8819
Mailing Address - Country:US
Mailing Address - Phone:786-468-5428
Mailing Address - Fax:
Practice Address - Street 1:14151 SW 275TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-8819
Practice Address - Country:US
Practice Address - Phone:786-468-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016781363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner