Provider Demographics
NPI:1205214541
Name:JOHNSON, SHANNAN
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1737 HOT SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N1737 HOT SPRINGS CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-8573
Practice Address - Country:US
Practice Address - Phone:920-358-4936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIJ52579393960072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer