Healthcare Provider Details

I. General information

NPI: 1437468295
Provider Name (Legal Business Name): SHIRLEY ANN SPILLER-JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 MONTREAT DR
MEMPHIS TN
38134-6613
US

IV. Provider business mailing address

2051 MONTREAT DR
MEMPHIS TN
38134-6613
US

V. Phone/Fax

Practice location:
  • Phone: 901-388-6903
  • Fax: 901-388-7366
Mailing address:
  • Phone: 901-388-6903
  • Fax: 901-388-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number00000565
License Number StateTN

VIII. Authorized Official

Name: MS. SHIRLEY ANN SPILLER-JOHNSON
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 901-388-6903