Healthcare Provider Details

I. General information

NPI: 1184568123
Provider Name (Legal Business Name): SHANNON JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. SHANNON CAVANAUGH

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WASHINGTON ST
WEST BEND WI
53095-2571
US

IV. Provider business mailing address

5761 N RIVER FOREST DR
GLENDALE WI
53209-4521
US

V. Phone/Fax

Practice location:
  • Phone: 262-338-2717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number18294-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: