Provider Demographics
NPI:1043234339
Name:JOHNSON, SHANNON MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 ASHLAND RD
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-1323
Mailing Address - Country:US
Mailing Address - Phone:606-473-5151
Mailing Address - Fax:606-473-0163
Practice Address - Street 1:2021 ASHLAND RD
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144-1323
Practice Address - Country:US
Practice Address - Phone:606-473-5151
Practice Address - Fax:606-473-0163
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85001295Medicaid
KY350043083OtherMEDICARE RR
KY350043083OtherMEDICARE RR
KY85001295Medicaid