Provider Demographics
NPI:1295923340
Name:JOHNSON, SHELLEY MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:MISS
First Name:SHELLEY
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26495
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95159-6495
Mailing Address - Country:US
Mailing Address - Phone:408-693-4291
Mailing Address - Fax:
Practice Address - Street 1:1055 N CAPITOL AVE
Practice Address - Street 2:#38
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95133-2701
Practice Address - Country:US
Practice Address - Phone:408-693-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480488163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse