Provider Demographics
NPI:1528600574
Name:JOHNSON, SHEARREN
Entity Type:Individual
Prefix:
First Name:SHEARREN
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 1:306 E YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75602-1114
Mailing Address - Country:US
Mailing Address - Phone:903-241-2233
Mailing Address - Fax:
Practice Address - Street 1:4293 KINSEY DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1004
Practice Address - Country:US
Practice Address - Phone:903-592-5670
Practice Address - Fax:903-363-9207
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143436207QA0505X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143436OtherSTATE LICENSE