Healthcare Provider Details

I. General information

NPI: 1619895083
Provider Name (Legal Business Name): TIJUANA MARIE JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N DEKALB ST
SHELBY NC
28150-3911
US

IV. Provider business mailing address

1405 BEVERLY AVE
SHELBY NC
28152-6305
US

V. Phone/Fax

Practice location:
  • Phone: 704-482-1482
  • Fax:
Mailing address:
  • Phone: 704-477-4348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5024837
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: