Basic Information
| Provider Information | |||||||||
| NPI: | 1104064831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHATONA | ||||||||
| MiddleName: | VANETTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4434 10TH ST | ||||||||
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| City: | BACLIFF | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775182217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815496447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 675876 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.