MEDICARE: MISS QUENA SHANTIECE JOHNSON RD/LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	4484	TN
2	133V00000X	Registered Dietitian	3175	OK

General Provider Information

NPI Number	:	1356133888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS QUENA SHANTIECE JOHNSON RD/LD

Provider Business Mailing Address
First Line	:	397 MADISON AVE APT 201
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-3411
Country	:	US
Telephone Number	:	901-314-8971
Fax Number	:

Provider Business Practice Location Address
First Line	:	397 MADISON AVE APT 201
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-3411
Country	:	US
Telephone Number	:	901-314-8971
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2025
Last Update Date	:	05/20/2025

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Directions to “ MISS QUENA SHANTIECE JOHNSON RD/LD” Practice Location

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