Provider Demographics
NPI:1336653682
Name:JOHNSON, SHELICE DELCENIA
Entity Type:Individual
Prefix:
First Name:SHELICE
Middle Name:DELCENIA
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 1:3236 SUNRISE VILLAGE LN APT B
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-5478
Mailing Address - Country:US
Mailing Address - Phone:770-361-8963
Mailing Address - Fax:
Practice Address - Street 1:3236 SUNRISE VILLAGE LN APT B
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5478
Practice Address - Country:US
Practice Address - Phone:770-361-8963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2017-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health