Provider Demographics
NPI:1154844942
Name:JOHNSON, SHANNON MARIE (PTA, BS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3213
Mailing Address - Country:US
Mailing Address - Phone:574-267-3500
Mailing Address - Fax:
Practice Address - Street 1:2304 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3213
Practice Address - Country:US
Practice Address - Phone:574-267-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005493A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant