Provider Demographics
NPI:1750872487
Name:JOHNSON, SHANTAE (NP-BC)
Entity type:Individual
Prefix:
First Name:SHANTAE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17520 W GRAND PKWY S
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4758
Mailing Address - Country:US
Mailing Address - Phone:281-725-5970
Mailing Address - Fax:
Practice Address - Street 1:17520 W GRAND PKWY S
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-4758
Practice Address - Country:US
Practice Address - Phone:812-725-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143150363LA2200X
MI4704278080NSA18533363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health