Provider Demographics
NPI:1720710791
Name:JOHNSON, SHAKITA (PMHNP)
Entity Type:Individual
Prefix:
First Name:SHAKITA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 KENSINGTON RD STE 212
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2197
Mailing Address - Country:US
Mailing Address - Phone:855-687-7861
Mailing Address - Fax:
Practice Address - Street 1:1520 KENSINGTON RD STE 212
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2197
Practice Address - Country:US
Practice Address - Phone:855-687-7861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN209025763363L00000X
IL041443879363LP0808X
IL209025763363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health