Provider Demographics
NPI:1164015913
Name:JOHNSON, SHAVONDA
Entity Type:Individual
Prefix:
First Name:SHAVONDA
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 1:1564 W 36TH PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-4503
Mailing Address - Country:US
Mailing Address - Phone:323-766-9415
Mailing Address - Fax:
Practice Address - Street 1:1564 W 36TH PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-4503
Practice Address - Country:US
Practice Address - Phone:323-766-9415
Practice Address - Fax:323-766-1710
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator