=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609611292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANTEL JOHNSON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2024
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 W MAGNOLIA AVE STE 201
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-7657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-702-2933
-----------------------------------------------------
Fax | 817-702-7315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17200 WESTGROVE DR APT 2421
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-7136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-548-1271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1169611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------