Healthcare Provider Details

I. General information

NPI: 1588595904
Provider Name (Legal Business Name): LEGACY CARE NURSING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEADOW VALLEY CT
MIDLAND GA
31820-4393
US

IV. Provider business mailing address

3240 DEVILLA TRCE
COLLEGE PARK GA
30349-4057
US

V. Phone/Fax

Practice location:
  • Phone: 706-464-1589
  • Fax:
Mailing address:
  • Phone: 678-488-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: SHAWNELL JOHNSON
Title or Position: COO
Credential: RN214043
Phone: 678-488-5380