Healthcare Provider Details

I. General information

NPI: 1043054091
Provider Name (Legal Business Name): SHIRA KAHLIAH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7823 PRESTON POINTE DR
FORT WAYNE IN
46804-5705
US

IV. Provider business mailing address

7823 PRESTON POINTE DR
FORT WAYNE IN
46804-5705
US

V. Phone/Fax

Practice location:
  • Phone: 260-205-4408
  • Fax:
Mailing address:
  • Phone: 260-205-4408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number240174571
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number240174571
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number240174571
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number240174571
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number24017457
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: