MEDICARE: LIGHT AT THE END PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1114690401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT AT THE END PLLC

Provider Business Mailing Address
First Line	:	21168 E OCOTILLO RD # 1045
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-8175
Country	:	US
Telephone Number	:	623-265-6220
Fax Number	:	866-491-7389

Provider Business Practice Location Address
First Line	:	21168 E OCOTILLO RD # 1045
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-8175
Country	:	US
Telephone Number	:	623-265-6220
Fax Number	:	866-491-7389

Authorized Official
Title or Position	:	CEO
Name	:	SHAVAUN J JOHNSON
Credential	:	DNP
Telephone Number	:	623-265-6220

Provider Enumeration Date	:	08/01/2021
Last Update Date	:	01/02/2026

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