Provider Demographics
NPI:1174184402
Name:JOHNSON, SHANNON SYMONE (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SYMONE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 COUNTRY VIEW LN APT 11D
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-8315
Mailing Address - Country:US
Mailing Address - Phone:419-322-0340
Mailing Address - Fax:
Practice Address - Street 1:1120 COUNTRY VIEW LN APT 11D
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-8315
Practice Address - Country:US
Practice Address - Phone:419-322-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.424265163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse