Provider Demographics
NPI:1336608009
Name:JOHNSON, SHELBY LEE (APRN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MAST DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6718
Mailing Address - Country:US
Mailing Address - Phone:919-771-0503
Mailing Address - Fax:
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:337-991-9276
Practice Address - Fax:337-943-0846
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2023-03-10
Deactivation Date:2023-02-15
Deactivation Code:
Reactivation Date:2023-03-09
Provider Licenses
StateLicense IDTaxonomies
VIAP13363363L00000X
NC5014122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner