Provider Demographics
NPI:1386940575
Name:JOHNSON, SHANNA MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-249-5698
Mailing Address - Fax:320-207-5719
Practice Address - Street 1:10625 W NORTH AVE STE 230
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-249-5698
Practice Address - Fax:320-207-5719
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI197266-30163W00000X
WI14417-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse