Provider Demographics
NPI:1548751340
Name:JOHNSON, SHANTA MARIE (CCMA)
Entity Type:Individual
Prefix:MRS
First Name:SHANTA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:MRS
Other - First Name:SHANTA
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCMA
Mailing Address - Street 1:113 22ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:CENTER POINT
Mailing Address - State:AL
Mailing Address - Zip Code:35215-4607
Mailing Address - Country:US
Mailing Address - Phone:850-737-7392
Mailing Address - Fax:
Practice Address - Street 1:113 22ND AVENUE SW
Practice Address - Street 2:
Practice Address - City:CENTERPOINT
Practice Address - State:AL
Practice Address - Zip Code:35215
Practice Address - Country:US
Practice Address - Phone:850-737-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
AL18023894374U00000X, 251E00000X
AL000000000374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL824882016Medicaid