Healthcare Provider Details

I. General information

NPI: 1659267011
Provider Name (Legal Business Name): SHENELL JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHENELL CAROLINE PATRIA BIRCH

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 STATE ST
MERIDEN CT
06450-3293
US

IV. Provider business mailing address

134 STATE ST
MERIDEN CT
06450-3293
US

V. Phone/Fax

Practice location:
  • Phone: 203-237-2229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15120
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number964168
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number224736
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: