Provider Demographics
NPI:1861126591
Name:JOHNSON, SHANDANESHA
Entity type:Individual
Prefix:DR
First Name:SHANDANESHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 MS HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:HOLCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:38940-9238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2033 NORMANDIE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2711
Practice Address - Country:US
Practice Address - Phone:720-660-5293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1312A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist