=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548751340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANTA MARIE JOHNSON CCMA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2018
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 22ND AVENUE SW
-----------------------------------------------------
City | CENTERPOINT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-737-7392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 22ND AVE NE
-----------------------------------------------------
City | CENTER POINT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35215-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-737-7392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 18023894
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 000000000
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 18023894
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------