Provider Demographics
NPI:1356702054
Name:JOHNSON, SHANTEA S (MS, MPH, CHES, CHC)
Entity type:Individual
Prefix:
First Name:SHANTEA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, MPH, CHES, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 NEW MACLAND RD
Mailing Address - Street 2:STE 200-129
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-2000
Mailing Address - Country:US
Mailing Address - Phone:678-770-5247
Mailing Address - Fax:
Practice Address - Street 1:3721 NEW MACLAND RD
Practice Address - Street 2:STE 200-129
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2000
Practice Address - Country:US
Practice Address - Phone:678-770-5247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA19853133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education