Provider Demographics
NPI:1902212608
Name:JOHNSTON, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12034 VILLA DORADO DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4747
Mailing Address - Country:US
Mailing Address - Phone:314-692-0703
Mailing Address - Fax:
Practice Address - Street 1:675 JUSTICE WAY RM C0049
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1574
Practice Address - Country:US
Practice Address - Phone:877-465-6650
Practice Address - Fax:804-294-2775
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014021871363L00000X, 363LF0000X
IL209.012733363LF0000X, 363L00000X
IN71015147A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily