Provider Demographics
NPI:1164016424
Name:JOHNSON, SHADONNA (NP)
Entity Type:Individual
Prefix:
First Name:SHADONNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-9117
Mailing Address - Country:US
Mailing Address - Phone:601-792-2078
Mailing Address - Fax:
Practice Address - Street 1:910 SECOND ST
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-9117
Practice Address - Country:US
Practice Address - Phone:601-792-2078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner