Provider Demographics
NPI:1497486757
Name:JOHNSON, SHANNON MAILE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MAILE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOVERNORS LN STE A
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-6300
Mailing Address - Country:US
Mailing Address - Phone:530-332-4650
Mailing Address - Fax:530-893-6921
Practice Address - Street 1:2 GOVERNORS LN STE A
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-6300
Practice Address - Country:US
Practice Address - Phone:530-332-4650
Practice Address - Fax:530-893-6921
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021365363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily