Basic Information
| Provider Information | |||||||||
| NPI: | 1992244800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHELLY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6107 IRONWOOD LN | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729168870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797694835 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7001 ROGERS AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A005000 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.