Healthcare Provider Details

I. General information

NPI: 1104334804
Provider Name (Legal Business Name): SHELBY MARIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 Q ST STE 500
LINCOLN NE
68503-3610
US

IV. Provider business mailing address

11284 BAUMAN AVE
OMAHA NE
68164-6807
US

V. Phone/Fax

Practice location:
  • Phone: 402-484-4940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number80348
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120522
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: