Provider Demographics
NPI:1114435484
Name:JOHNSON, SHANNON MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 OLD COWAN RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1913
Mailing Address - Country:US
Mailing Address - Phone:931-962-1004
Mailing Address - Fax:931-962-1400
Practice Address - Street 1:120 HORTON LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:TN
Practice Address - Zip Code:37306-2109
Practice Address - Country:US
Practice Address - Phone:931-308-6537
Practice Address - Fax:931-308-6537
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily