MEDICARE: SHATERIA JOHNSON

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	332BC3200X	Customized Equipment (DME)		TX
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1649932492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHATERIA JOHNSON

Provider Business Mailing Address
First Line	:	850 LAKE CAROLYN PKWY APT 3146
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75039-4440
Country	:	US
Telephone Number	:	469-864-9931
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 LAKE CAROLYN PKWY APT 3146
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75039-4440
Country	:	US
Telephone Number	:	469-864-9931
Fax Number	:

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

Provider Enumeration Date	:	10/08/2021
Last Update Date	:	10/08/2021

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Directions to “ SHATERIA JOHNSON ” Practice Location

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