Provider Demographics
NPI:1992244800
Name:JOHNSON, SHELLY (APRN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 IRONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8870
Mailing Address - Country:US
Mailing Address - Phone:479-769-4835
Mailing Address - Fax:
Practice Address - Street 1:7001 ROGERS AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-314-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily