Provider Demographics
NPI:1558685156
Name:ESTES, JOHANNA SHEA (RD, IBCLC, MSNFNP-C)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:SHEA
Last Name:ESTES
Suffix:
Gender:F
Credentials:RD, IBCLC, MSNFNP-C
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:SHEA
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 DOCTORS PARK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6224
Mailing Address - Country:US
Mailing Address - Phone:618-244-5500
Mailing Address - Fax:618-246-1247
Practice Address - Street 1:4101 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-244-6222
Practice Address - Fax:618-246-1247
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027598363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner