Provider Demographics
NPI:1972215382
Name:JOHNSON, SHAMEKA LOGAN
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:LOGAN
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 1:2305 WELLINGTON DR SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4400
Mailing Address - Country:US
Mailing Address - Phone:252-306-7474
Mailing Address - Fax:
Practice Address - Street 1:2305 WELLINGTON DR SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4400
Practice Address - Country:US
Practice Address - Phone:252-306-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185817163WP0807X
NC2022009320363LP0808X
NC5017490363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health