Healthcare Provider Details

I. General information

NPI: 1558297499
Provider Name (Legal Business Name): SHANNAN JOHNSON NP STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 ROGERS AVE
FORT SMITH AR
72903-4100
US

IV. Provider business mailing address

105 ELFEN GLEN ST
VAN BUREN AR
72956-2223
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-6000
  • Fax:
Mailing address:
  • Phone: 501-672-9207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSTUDENT
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: