Healthcare Provider Details

I. General information

NPI: 1114435484
Provider Name (Legal Business Name): SHANNON MARIE JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 02/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HORTON LN
BELVIDERE TN
37306-2109
US

IV. Provider business mailing address

1509 OLD COWAN RD
WINCHESTER TN
37398-1913
US

V. Phone/Fax

Practice location:
  • Phone: 931-308-6537
  • Fax: 931-308-6537
Mailing address:
  • Phone: 931-962-1004
  • Fax: 931-962-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23682
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: