Provider Demographics
NPI:1023608049
Name:JOHNSON, SHELLISE
Entity type:Individual
Prefix:
First Name:SHELLISE
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 1:703 MACDILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-3794
Mailing Address - Country:US
Mailing Address - Phone:443-310-8579
Mailing Address - Fax:
Practice Address - Street 1:1703 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3745
Practice Address - Country:US
Practice Address - Phone:443-869-6882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3875310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility