Provider Demographics
NPI:1053016782
Name:JOHNSON, SHAVONNA TIQUANNA
Entity type:Individual
Prefix:
First Name:SHAVONNA
Middle Name:TIQUANNA
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 1:1318 MONTELLO AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3820
Mailing Address - Country:US
Mailing Address - Phone:202-696-6078
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health