Provider Demographics
NPI:1639166499
Name:JOHNSON, SHANNON L (CNP, APRN, CNS-RX)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP, APRN, CNS-RX
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:CLINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:STE. 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-425-8100
Mailing Address - Fax:405-425-8109
Practice Address - Street 1:1600 SW 119TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4908
Practice Address - Country:US
Practice Address - Phone:405-425-8100
Practice Address - Fax:405-425-8109
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60090363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200030250AMedicaid
OK200030250AMedicaid
OKQ14135Medicare UPIN