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General NPI Number Information
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NPI Number | 1497304646
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Entity Type | Individual
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Provider Name | SHANTAE RENEE JOHNSON
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Gender | Female
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Dates
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Enumeration Date | 09/10/2019
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Last Update Date | 09/10/2019
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Provider Practice Location Address
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Address Line | 560 BIG SIOUX CT
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City | POINCIANA
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State | FL
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Zip | 34759-5927
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Country | US
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Telephone | 863-205-7815
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Fax | 863-496-7722
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Provider Business Mailing Address
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Address Line | 560 BIG SIOUX CT
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City | POINCIANA
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State | FL
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Zip | 34759-5927
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Country | US
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Telephone | 863-205-7815
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | 221013
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License Number State | FL
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