Individual
SHANTAE RENEE JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
560 BIG SIOUX CT, POINCIANA, FL 34759-5927
(863) 205-7815
(863) 496-7722
Mailing address
560 BIG SIOUX CT, POINCIANA, FL 34759-5927
(863) 205-7815
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
221013
FL
Other
Enumeration date
09/10/2019
Last updated
09/10/2019
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