Healthcare Provider Details

I. General information

NPI: 1770493546
Provider Name (Legal Business Name): SHIYA LATTERRICE JOHNSON C.N.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W HEADING AVE # 312
WEST PEORIA IL
61604-4971
US

IV. Provider business mailing address

2619 W HEADING AVE # 312
WEST PEORIA IL
61604-4971
US

V. Phone/Fax

Practice location:
  • Phone: 573-577-8099
  • Fax: --
Mailing address:
  • Phone: 573-577-8099
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: