Provider Demographics
NPI:1972018125
Name:JOHNSON, SHATONNA
Entity Type:Individual
Prefix:
First Name:SHATONNA
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 1:1930 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1416
Mailing Address - Country:US
Mailing Address - Phone:779-208-6179
Mailing Address - Fax:779-208-6179
Practice Address - Street 1:318 MIRIAM AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-5534
Practice Address - Country:US
Practice Address - Phone:779-208-6179
Practice Address - Fax:779-208-6179
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide