Healthcare Provider Details

I. General information

NPI: 1629972252
Provider Name (Legal Business Name): SHANTRICE JOHNSON CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER DR
HARDEEVILLE SC
29927-3446
US

IV. Provider business mailing address

680 OLD OLIVE BRANCH RD
ELLABELL GA
31308-4845
US

V. Phone/Fax

Practice location:
  • Phone: 843-784-8000
  • Fax:
Mailing address:
  • Phone: 912-856-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number184502
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: