Provider Demographics
NPI:1457096349
Name:JOHNSON, SHANNON MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 HIGHWAY 7 S
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5392
Mailing Address - Country:US
Mailing Address - Phone:662-234-7521
Mailing Address - Fax:
Practice Address - Street 1:152 HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5392
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MS337432164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS337432OtherLPN LICENSE NUMBER