Provider Demographics
NPI:1841303856
Name:JOHNSON, SHANA L (CNM)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:L
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:12303 NE 130TH LN
Mailing Address - Street 2:SUITE 225
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3099
Mailing Address - Country:US
Mailing Address - Phone:425-899-4012
Mailing Address - Fax:425-899-4013
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 225
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-4012
Practice Address - Fax:425-899-4013
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200141902RN163W00000X
OR200250004NP363LW0102X
WAAP60052156363L00000X
WARN00175004163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028169Medicaid
OR028169Medicaid