Healthcare Provider Details

I. General information

NPI: 1558665018
Provider Name (Legal Business Name): SHEREKA A JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2010
Last Update Date: 02/09/2021
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MATTHEWS ST
GOSHEN NY
10924-1995
US

IV. Provider business mailing address

PO BOX 355
POMONA NY
10970-0355
US

V. Phone/Fax

Practice location:
  • Phone: 347-393-6500
  • Fax:
Mailing address:
  • Phone: 347-393-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number298220
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF310116-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: