Provider Demographics
NPI:1043085145
Name:JOHNSON, STEPHANIE KRYSTIE (AGNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KRYSTIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 GOLDEN GRAIN DR
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-9773
Mailing Address - Country:US
Mailing Address - Phone:317-701-2379
Mailing Address - Fax:
Practice Address - Street 1:3743 GOLDEN GRAIN DR
Practice Address - Street 2:
Practice Address - City:WHITESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46075-9773
Practice Address - Country:US
Practice Address - Phone:317-701-2379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28225777A363LG0600X
IN71014713A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology