MEDICARE: SHANNON JOHNSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	2014021871	MO
2	363L00000X	Nurse Practitioner	209.012733	IL
3	363LF0000X	Family Nurse Practitioner	209.012733	IL
4	363LF0000X	Family Nurse Practitioner	2014021871	MO
5	363L00000X	Nurse Practitioner	71015147A	IN

General Provider Information

NPI Number	:	1902212608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON JOHNSTON

Provider Business Mailing Address
First Line	:	12034 VILLA DORADO DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4747
Country	:	US
Telephone Number	:	314-692-0703
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 JUSTICE WAY RM C0049
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-1574
Country	:	US
Telephone Number	:	877-465-6650
Fax Number	:	804-294-2775

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	07/31/2025

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Directions to “ SHANNON JOHNSTON ” Practice Location

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