Provider Demographics
NPI:1801080619
Name:JOHNSON, SHANNON MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HIGHWAY 252
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5054
Mailing Address - Country:US
Mailing Address - Phone:864-654-1500
Mailing Address - Fax:
Practice Address - Street 1:7900 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-8876
Practice Address - Country:US
Practice Address - Phone:864-654-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily