Provider Demographics
NPI:1710443767
Name:JOHNSON, ANTALLIA SHAUNTELL (CRNP)
Entity Type:Individual
Prefix:
First Name:ANTALLIA
Middle Name:SHAUNTELL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 US HWY 431 WOMEN'S CENTER SUITE A
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957
Mailing Address - Country:US
Mailing Address - Phone:256-840-4530
Mailing Address - Fax:256-840-4537
Practice Address - Street 1:2505 US HWY 431 WOMEN'S CENTER SUITE A
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-840-4530
Practice Address - Fax:256-840-4537
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-154179363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology