Provider Demographics
NPI:1740678960
Name:SPILLER-JOHNSON, SHIRLEY (ADMINISTRATOR/OPERAT)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:SPILLER-JOHNSON
Suffix:
Gender:F
Credentials:ADMINISTRATOR/OPERAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 MONTREAT DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-6613
Mailing Address - Country:US
Mailing Address - Phone:901-598-7437
Mailing Address - Fax:901-388-7366
Practice Address - Street 1:2051 MONTREAT DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-6613
Practice Address - Country:US
Practice Address - Phone:901-598-7437
Practice Address - Fax:901-388-7366
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000565164W00000X, 372500000X, 372600000X, 3747A0650X, 3747P1801X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445488Medicaid