Provider Demographics
NPI:1255843033
Name:JOHNSON, SHANNON VICTORIA (WHNP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:VICTORIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-9600
Mailing Address - Country:US
Mailing Address - Phone:954-599-6041
Mailing Address - Fax:
Practice Address - Street 1:210 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-389-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901996363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health