Provider Demographics
NPI:1528070471
Name:JOHNSON, SHANDA (APN,C)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 7TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-1643
Mailing Address - Country:US
Mailing Address - Phone:908-757-8687
Mailing Address - Fax:908-757-8685
Practice Address - Street 1:120 W 7TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-1643
Practice Address - Country:US
Practice Address - Phone:908-757-8687
Practice Address - Fax:908-757-8685
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00051500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ124061XVAMedicare UPIN