Healthcare Provider Details

I. General information

NPI: 1619194727
Provider Name (Legal Business Name): SUSAN JOHNSON SHANNON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 PARAGON PKWY SUITE 800
CLYDE NC
28721-9481
US

IV. Provider business mailing address

1367 CRAWFORD RD
WAYNESVILLE NC
28785-9638
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-6675
  • Fax: 828-452-6730
Mailing address:
  • Phone: 828-627-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number125103
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: