Provider Demographics
NPI:1467063388
Name:JOHNSON, SHANDAR LEE
Entity Type:Individual
Prefix:
First Name:SHANDAR
Middle Name:LEE
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 1:6965 SARANAC ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1747
Mailing Address - Country:US
Mailing Address - Phone:619-829-4584
Mailing Address - Fax:
Practice Address - Street 1:9228 ALLANO WAY
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-2202
Practice Address - Country:US
Practice Address - Phone:619-829-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4559925OtherDRIVER LICENSE