Healthcare Provider Details

I. General information

NPI: 1164129169
Provider Name (Legal Business Name): SHAWNTATE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

IV. Provider business mailing address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-5290
  • Fax: 510-981-5265
Mailing address:
  • Phone: 510-981-5290
  • Fax: 510-981-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: