Healthcare Provider Details

I. General information

NPI: 1487457438
Provider Name (Legal Business Name): SHYANNE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 W CHARLESTON BLVD
LAS VEGAS NV
89102-1942
US

IV. Provider business mailing address

2820 W CHARLESTON BLVD
LAS VEGAS NV
89102-1942
US

V. Phone/Fax

Practice location:
  • Phone: 702-682-2535
  • Fax:
Mailing address:
  • Phone: 702-682-2535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: