Provider Demographics
NPI:1821789082
Name:JOHNSON, SHANAYA
Entity Type:Individual
Prefix:
First Name:SHANAYA
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 1:2519 GERMANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-1636
Mailing Address - Country:US
Mailing Address - Phone:610-712-0795
Mailing Address - Fax:
Practice Address - Street 1:2519 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-1636
Practice Address - Country:US
Practice Address - Phone:610-712-0795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA70683601385H00000X, 253Z00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty