MEDICARE: SHANEKA ELISE JOHNSON

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	163W00000X	Registered Nurse	254818	NC

General Provider Information

NPI Number	:	1598442030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEKA ELISE JOHNSON

Provider Business Mailing Address
First Line	:	5122 CHESTNUT LAKE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-4928
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5122 CHESTNUT LAKE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-4928
Country	:	US
Telephone Number	:	336-405-2900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2023
Last Update Date	:	06/28/2023

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