Provider Demographics
NPI:1134609464
Name:JOHNSON, SHAMIRA CLINTONIA (CNA)
Entity type:Individual
Prefix:MS
First Name:SHAMIRA
Middle Name:CLINTONIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-4311
Mailing Address - Country:US
Mailing Address - Phone:610-803-5484
Mailing Address - Fax:610-874-5837
Practice Address - Street 1:217 W 5TH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-803-5484
Practice Address - Fax:610-874-5837
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10019808376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10019808OtherNURSES AIDE REGISTRY
PA6754270OtherSTATE ENTITY NUMBER