Healthcare Provider Details

I. General information

NPI: 1528070471
Provider Name (Legal Business Name): SHANDA JOHNSON APN,C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 7TH ST SUITE 203
PLAINFIELD NJ
07060-1643
US

IV. Provider business mailing address

120 W 7TH ST SUITE 203
PLAINFIELD NJ
07060-1643
US

V. Phone/Fax

Practice location:
  • Phone: 908-757-8687
  • Fax: 908-757-8685
Mailing address:
  • Phone: 908-757-8687
  • Fax: 908-757-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00051500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: