Provider Demographics
NPI:1548901127
Name:JOHNSON, SHELBY LOUISE (MD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 N JUBILEE CT
Mailing Address - Street 2:
Mailing Address - City:HAINESVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4721
Mailing Address - Country:US
Mailing Address - Phone:509-793-5428
Mailing Address - Fax:
Practice Address - Street 1:7435 W TALCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3707
Practice Address - Country:US
Practice Address - Phone:773-990-7921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine