MEDICARE: MRS. SHALLON TENNILLE JOHNSON FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0037086	OH

General Provider Information

NPI Number	:	1104660273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHALLON TENNILLE JOHNSON FNP-C

Provider Business Mailing Address
First Line	:	10850 MAHONING AVE
Second Line	:
City	:	NORTH JACKSON
State	:	OH
Zip	:	44451-8705
Country	:	US
Telephone Number	:	330-331-4966
Fax Number	:	234-888-7281

Provider Business Practice Location Address
First Line	:	10850 MAHONING AVE
Second Line	:
City	:	NORTH JACKSON
State	:	OH
Zip	:	44451-8705
Country	:	US
Telephone Number	:	330-331-4966
Fax Number	:	234-888-7281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2024
Last Update Date	:	08/27/2025

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