Provider Demographics
NPI:1528734548
Name:JOHNSON, SHANTANA D
Entity type:Individual
Prefix:MRS
First Name:SHANTANA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHANTANA
Other - Middle Name:D
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1190 BLARNEY ST
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-7634
Mailing Address - Country:US
Mailing Address - Phone:321-217-2409
Mailing Address - Fax:855-257-1340
Practice Address - Street 1:1920 VERANO DR STE 105
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-8585
Practice Address - Country:US
Practice Address - Phone:321-217-2409
Practice Address - Fax:855-257-1340
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X, 253Z00000X, 320600000X, 385HR2055X, 376J00000X, 385H00000X, 385HR2050X, 385HR2060X, 385HR2065X
FL299995365251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022449300Medicaid
FL108545900Medicaid